Vademecum Metabolicum

Inside front cover
Patterns of acute presentation
Main problem See page

The “metabolic emergency” 3
Early-onset seizures 15
Cardiomyopathy 16
Liver failure 19
Acute life-threatening episode, SIDS 24
Post-mortem investigations 25
Important laboratory findings
Main problem See page

Hypoglycaemia 6
Hyperammonaemia 8
Metabolic acidosis 11
Elevated lactate 13
Inside back cover
Emergency medication
Medication that should be available in every children’s hospital (intensive care unit)
Drug Preparation Dose (emergency administration)

Biotin e.g. 5 mg tablets 10–15 mg/day (oral; in one dose)
Diazoxide e.g. 25 mg capsules 15 mg/kg/day (oral; in 3 doses)
Folic acid e.g. 5 mg/ml ampules 15 mg/kg/day (i.v.; in 3 doses)
Folinic acid e.g. 10 mg/ml ampules 3 mg/kg/day (i.v.; in one dose)
(Ca-folinate)
Glucagon e.g. 1 mg/ml ampules i.v. bolus: 30–100 µg/kg (max. 1 mg);
maintenance infusion: 5–10 µg/kg/hr
Hydroxocobal- e.g. 0.5 mg/ml, 5 mg/ml 1(–5) mg/day (i.m./i.v.; single dose)
amin (B12) ampules
L-Arginine-HCl L-Arg hydrochloride 21%: Short infusion: 2 mmol/kg/90 min;
1 ml = 1 mmol L-arginine maintenance inf.: 2–4 mmol/kg/day
L-Carnitine e.g. 200 mg/ml ampules i.v. bolus: 50 mg/kg (organic
acidurias); maintenance infusion:
50–200 mg/kg/day
Na-benzoate 3% solution = 30 mg/ml Short infusion: 250 mg/kg over 2 hrs;
10% solution = 100 mg/ml maintenance infusion: 250 mg/kg/day
Na-phenyl- Powder or tablets; 1 g = 250 mg/kg/day (oral; in 3 doses)
butyrate 940 mg active ingredient
Pyridoxal No licenced medication, 30 mg/kg/day (oral; in 3 doses)
phosphate chemical preparations only
Pyridoxine-HCl e.g. 50 mg/ml ampules 100(–500) mg (i.v.; single dose)
(Vitamin B6)
Trometamol Equimolar for buffering when Na+ is
(Tham buffer) high
Dilute drugs for infusion in 30 ml/kg glucose 10%. Give as bypass to running infusion.
Do not forget to include calories, sodium and fluids in the i.v. intake calculations.
L-Carnitine, L-arginine and Na-benzoate may be mixed in a single bypass tube.
Opposite inside back cover
Special emergency medication

Special medication that may be used in metabolic centres
Drug Preparation Dose (emergency administration)

Betaine 180 g powder for oral 250 mg/kg/day (oral; in 2 doses)
anhydrous solution
Carbamyl- 200 mg tablets 100 mg/kg/day (oral; in 3 doses)
glutamate
Diazoxide 15 mg/kg/day (oral; in 3 doses)
L-Isoleucine 5–20 mg/kg/day (oral; in 3–5 doses)
L-Valine 5–20 mg/kg/day (oral; in 3–5 doses)
L-Methionine 100 mg/kg/day (oral; in 3 doses)
Nitisinone 2 mg capsules 1 mg/kg/day (oral; in 2–3 doses)
(NTBC)
Riboflavin e.g. 5 mg/ml or 14.6 mg/ml 150 mg/day (i.v.; in 3 doses)
(Vitamin B2) ampules (active ingredient) (e.g. 3 ampules three times daily)
Somatostatin e.g. 3 mg powder 1–5 µg/kg/hr (i.v.)
Thiamine-HCl e.g. 50 mg/ml ampules Age 0–3 yrs: 150 mg/day; age > 3 yrs:
(Vitamin B1) 300 mg/day; (i.v., in 3 doses)
Johannes Zschocke
Georg F. Hoffmann
Vademecum Metabolicum
Vademecum
Metabolicum
Manual of Metabolic Paediatrics
2nd Edition
Johannes Zschocke, Heidelberg

Georg F. Hoffmann, Heidelberg
Foreword by
James V. Leonard, London
Contributors:
Alberto B. Burlina, Padova
Marinus Duran, Amsterdam
James V. Leonard, London
Ertan Mayatepek, Düsseldorf
Verena Peters, Heidelberg
Jan A. M. Smeitink, Nijmegen
Jerry Vockley, Pittsburgh
Udo Wendel, Düsseldorf
Johannes Zschocke, Dr. med. habil., Ph. D.
Senior Human Geneticist
Institute of Human Genetics,
Ruprecht-Karls-University,
Im Neuenheimer Feld 366, 69120 Heidelberg
Germany
Georg F. Hoffmann, Dr. med. habil.

Professor of Paediatrics
University Children’s Hospital,
Ruprecht-Karls-University,
Im Neuenheimer Feld 150, 69120 Heidelberg
Germany
This edition corresponds to the third German and Italian editions.
Bibliographic information published by Die Deutsche Bibliothek

Die Deutsche Bibliothek lists this publication in the Deutsche
Nationalbibliografie; detailed bibliographic data is available in the
Internet at < http://dnb.ddb.de> .
Important note: Medicine is an ever-changing science, so the contents of this

publication, especially recommendations concerning diagnostic and therapeutic
procedures, can only give an account of the knowledge at the time of publication. While
utmost care has been taken to ensure that all specifications regarding drug selection and
dosage and treatment options are accurate, readers are urged to review the product
information sheet and any relevant material supplied by the manufacturer, and, in case of
doubt, to consult a specialist. The publisher will appreciate – also in the public’s interest
– to be informed of possible inconsistencies. The ultimate responsibility for any
diagnostic or therapeutic application lies with the reader.
No special reference is made to registered names, proprietary names, trade marks etc. in
this publication. The appearance of a name without designation as proprietary does not
imply that it is exempt from the relevant protective laws and regulations and therefore
free for general use.
This publication is subject to copyright, all rights are reserved, whether the whole or part
of the material is concerned, specifically the rights of translation, reprinting, duplication,
reproduction on microfilm, and storage in electronic retrieval systems, including the
internet and intranets. Any use of this publication outside the limits set by copyright
legislation, without the prior written permission of the publisher or authors, is liable to
prosecution.
Copyright !
First Edition, 1999
Second Edition, 2004 by
Milupa GmbH & Co. KG, 61381 Friedrichsdorf, Germany
Printed in Germany
Edited and Preparations of the camera-ready manuscript by the authors

Printing and binding: !!!!!!
Printed on paper bleached without chlorine or acid.
ISBN 3-7945-2385-7
Foreword
It is a pleasure to write a foreword to the latest edition of the Vademecum Metabolicum.

It has already demonstrated its value worldwide with versions in German, Chinese,
English, French, Hungarian and Italian. In this edition important changes have been
made, introducing a more problem orientated approach to the diagnosis. I am sure that
this will make it easier and quicker to diagnose patients with metabolic disorders. This
will also mean further improvements in management and hence outcome.
August 2004
Institute of Child Health, London, UK James V. Leonard
Forword to the 1st edition
Metabolic disorders in children are not common, and many paediatricians, both senior
and junior, have only limited experience of them. The presentation is initially often non-
specific, which can make the diagnosis difficult. Thus there is a need for help with the
diagnosis and immediate management at the point of contact with the patient. This
practical short book bridges a gap for the busy clinician between paediatric textbooks
with little detail and much larger specialised ones. The goal is to help make the diagnosis
more quickly, to assist with the management and therefore to improve all aspects of the
long- term outcome. It surely will succeed in all three of these.
August 1999
Institute of Child Health, London, UK James V. Leonard
Preface
Inborn errors of metabolism, which cumulatively affect approximately one in 500

newborns, represent a special challenge in general and paediatric practice. They
frequently present with acute, life-threatening crises that require immediate specific
intervention. The development and prognosis of the affected child may depend on rapid
and effective treatment, but the large number of genetic defects in various biochemical
pathways makes it difficult to be familiar with all diagnostic strategies and specific
therapies. With this in mind, the Vademecum Metabolicum aims to provide practical
guidance to the clinician.
This 2nd English edition has been updated and expanded. The first section on the
diagnosis and management of metabolic disorders now includes a much greater number
of clinical situations that may be caused by a metabolic disorder. Practical guidelines
have been discussed in detail by the authors and contributors and should reflect standard
practice in many countries. Several function tests have now been removed as they are
rarely used even in specialised centres. In the second section on individual metabolic
pathways and their disorders, a considerable number of recently identified disorders has
been included. As in the previous editions, special emphasis has been placed on clinical
features that are relevant to a whole group of diseases, useful diagnostic procedures
(basic and special diagnostic tests) as well as details on emergency intervention and long-
term treatment. The pathobiochemistry is described in more detail when it is relevant to
the understanding of clinical symptoms and diagnostic tests. The sequence of the entries
is either according to metabolic pathways or nomenclature.
We are grateful for important comments by Drs Dorothea Haas, Martin Lindner, Viola
Prietsch, Oliver Sass, Andreas Schulze and Nicole Wolf. Again we are indebted to Dr.
Beate Szczerbak, Milupa, Friedrichsdorf, for her unwavering, continuous support. The
friendly and professional help of Dr. Wulf Bertram and his colleagues at Schattauer
Publishing, Stuttgart, is gratefully acknowledged.
Heidelberg, August 2004 Johannes Zschocke

Georg Friedrich Hoffmann
Table of contents
Diagnosis and management of metabolic disorders..............1
Essential basic laboratory tests .......................................................................1
General clinical situations.................................................................................3

The metabolic emergency ................................................................................................. 3
Hypoglycaemia.................................................................................................................. 6
Hyperammonaemia ........................................................................................................... 8
Metabolic acidosis and ketosis........................................................................................ 11
Elevated lactate ............................................................................................................... 13
Psychomotor retardation ................................................................................................. 14
Epileptic encephalopathy ................................................................................................ 15
The floppy infant............................................................................................................. 15
Exercise intolerance ........................................................................................................ 16
Cardiomyopathy .............................................................................................................. 16
Dysmorphic features ....................................................................................................... 18
Liver disease.................................................................................................................... 19
Reye-like syndrome......................................................................................................... 24
Sudden unexpected death (in infancy) ............................................................................ 24
Post-mortem investigations ............................................................................................. 25
Fetal hydrops ................................................................................................................... 26
Unusual clinical observations ......................................................................................... 27
Unusual laboratory findings ............................................................................................ 28
Special metabolic investigations are not required in ...................................................... 29
Special metabolic investigations....................................................................30

Simple metabolic urine tests ........................................................................................... 30
Amino acids (AA) ........................................................................................................... 31
Organic acids (OA) ......................................................................................................... 33
Carnitine analyses ........................................................................................................... 34
Other special metabolic investigations............................................................................ 35
Biopsies and enzyme studies........................................................................................... 39
Molecular genetic investigations..................................................................................... 40
Diagnosis of neurometabolic disorders........................................................................... 42
Function tests...................................................................................................44
Metabolic Profiling ......................................................................................................... 44
Glucose challenge ........................................................................................................... 45
Fasting test ...................................................................................................................... 46
Glucagon Test ................................................................................................................. 48
Tetrahydrobiopterin (BH4) test........................................................................................ 49
Phenylalanine challenge.................................................................................................. 50
Allopurinol test................................................................................................................ 51
Forearm ischaemia test .................................................................................................... 52
Neonatal screening ..........................................................................................53

What to do when galactose is elevated............................................................................ 53
What to do when phenylalanine is elevated .................................................................... 54
Tandem mass spectroscopy (tandem MS) ....................................................................... 55
Metabolic pathways and their disorders ............................... 57
Amino acid and protein metabolism...............................................................57

Principles of treatment..................................................................................................... 58
Disorders of ammonia detoxification – urea cycle defects ............................................. 61
Classical organic acidurias .............................................................................................. 65
“Cerebral” organic acidurias ........................................................................................... 67
Disorders of biotin metabolism ....................................................................................... 69
Disorders of the metabolism of branched-chain amino acids ......................................... 70
Disorders of phenylalanine and tyrosine metabolism...................................................... 71
Disorders of histidine metabolism................................................................................... 73
Disorders of lysine and tryptophan metabolism .............................................................. 74
Disorders of cytosolic methyl group transfer
and the metabolism of sulphur amino acids .................................................................... 75
Disorders of cobalamin metabolism................................................................................ 77
Disorders of serine and glycine metabolism ................................................................... 79
Disorders of ornithine and proline metabolism............................................................... 81
Disorders of amino acid transport ................................................................................... 82
Disorders of the gamma-glutamyl cycle.......................................................................... 83
Disorders of peptide metabolism..................................................................................... 85
Energy metabolism ..........................................................................................86

Mitochondrial disorders .................................................................................................. 87
Disorders of fatty acid oxidation and ketogenesis........................................................... 94
Disorders of ketolysis ...................................................................................................... 98
Disorders of creatine biosynthesis................................................................................... 98
Carbohydrate metabolism .............................................................................100

Disorders of galactose and fructose metabolism........................................................... 101
Disorders of gluconeogenesis........................................................................................ 103
Glycogen storage diseases............................................................................................. 104
Disorders of glycerol metabolism ................................................................................. 106
Disorders of pentose metabolism .................................................................................. 107
Disorders of glucose transport....................................................................................... 108
Congenital hyperinsulinism (CHI) ................................................................................ 109
Lysosomal metabolism..................................................................................111
Mucopolysaccharidoses (MPS) ..................................................................................... 114
Oligosaccharidoses........................................................................................................ 117
Sphingolipidoses ........................................................................................................... 118
Mucolipidoses ............................................................................................................... 121
Lipid storage disorders .................................................................................................. 121
Lysosomal transport defects .......................................................................................... 122
Neuronal ceroid lipofuscinoses ..................................................................................... 123
Peroxisomal metabolism ...............................................................................124
Sterol metabolism ..........................................................................................127

Disorders of sterol biosynthesis .................................................................................... 127
Disorders of bile acid synthesis..................................................................................... 130
Protein glycosylation .....................................................................................131

Congenital disorders of glycosylation (CDG)............................................................... 131
Lipoprotein metabolism.................................................................................134
Hypercholesterolaemias ................................................................................................ 135
Mixed hyperlipidaemias ................................................................................................ 136
Hypertriglyceridaemias ................................................................................................. 137
Disorders of HDL metabolism ...................................................................................... 137
Disorders with decreased LDL cholesterol and triglycerides ....................................... 138
Purine and pyrimidine metabolism...............................................................139

Disorders of purine metabolism .................................................................................... 140
Disorders of pyrimidine metabolism............................................................................. 142
Other disorders of nucleotide metabolism .................................................................... 143
Neurotransmission.........................................................................................144
Disorders of biogenic amine metabolism...................................................................... 144
Disorders of GABA metabolism................................................................................... 147
Disorders of pyridoxine metabolism ............................................................................. 148
Other neurotransmitter defects...................................................................................... 149
Other metabolic pathways.............................................................................150

Porphyrias...................................................................................................................... 150
Disorders of transport or utilisation of metals............................................................... 151
Miscellaneous progressive neurological disorders........................................................ 153
Miscellaneous disorders with mostly hepatic presentation ........................................... 154
Other metabolic disorders ............................................................................................. 156
Appendix.................................................................................157
Helpful internet resources ............................................................................................. 157
Free fatty acids and 3-hydroxybutyrate during fasting.................................................. 158
Index........................................................................................159
Abbreviations
AA amino acids OH- hydroxy-

AFP !-fetoprotein OTC ornithine transcarbamylase
ALT alanine aminotransferase P phosphate
AST aspartate aminotransferase PA propionic aciduria
BH4 tetrahydrobiopterin PALP pyridoxal phosphate
Bioch. biochemistry PC pyruvate carboxylase
Cbl cobalamin PDH pyruvate dehydrogenase
CDG congenital disorders of PKU phenylketonuria
glycosylation Progn.prognosis
CK creatine kinase SCAD short-chain acyl-CoA DH
CoA coenzyme A SCHAD short-chain hydroxyacyl-CoA
Compl. complication dehydrogenase
CPT carnitine palmitoyltransferase SIDS sudden infant death syndrome
CSF cerebrospinal fluid VLCAD (very)-long-chain acyl-CoA
DD differential diagnosis dehydrogenase
DH dehydrogenase wk week
Diagn. diagnosis yr year
FA fatty acids
FFA free fatty acids Amino acids
Fru fructose Ala alanine
GABA "-aminobutyric acid Arg arginine
GAG glycosaminoglycans Asa argininosuccinic acid
Gal galactose Asn asparagine
GALT galactose-1-phosphate uridyl- Asp aspartate
transferase Cit citrulline
GC gas chromatography Cys cysteine
Glc glucose Gln glutamine
HMG 3-hydroxy-3-methylglutarate Glu glutamate
HPLC high performance liquid Gly glycine
chromatography Hcy homocysteine
IVA Isovaleric aciduria His histidine
Manif. manifestation Ile isoleucine
MCAD medium-chain acyl-CoA DH Leu leucine
MMA methylmalonic aciduria Lys lysine
MPS mucopolysaccharide(-osis) Met methionine
MRI magnetic resonance imaging Orn ornithine
MRS magnetic resonance Phe phenylalanine
spectroscopy Pro proline
MS mass spectroscopy Ser serine
mth month Tau taurine
n normal Thr threonine
NH3 ammonia Trp tryptophan
NMR nuclear magnetic resonance Tyr tyrosine
OA organic acids Val valine
1
Diagnosis and management of

metabolic disorders
Essential basic laboratory tests

The following basic laboratory tests should be performed in every child with an acute
illness in whom a metabolic disorder is a possibility:
Blood glucose
Hypoglycaemia is a presenting feature of several disorders particularly of carbohydrate
and energy metabolism. Appropriate blood and urine samples should be obtained in the
acute phase to make the correct diagnosis. For details see page 6.
Ammonia
Ammonia is highly neurotoxic and hyperammonaemia carries a high but in principle
avoidable mortality and morbidity. Urgent analysis of the plasma ammonia concentration
is mandatory in all acutely ill neonates and all patients with undiagnosed encephalopathy.
Facilities to determine ammonia at any time of the day should be available in all
hospitals. Hyperammonaemia due to a primary urea cycle disorder is among the most
urgent emergencies in metabolic paediatrics and will be missed if ammonia is not
measured. For details see page 8.
Acid-base status
Many metabolic disorders cause alterations in the acid-base status, both acidosis and
alkalosis. Blood gas measurements need to be available at any time in every hospital. For
details see page 11.
Lactate
Elevated lactate is an important sequel of hypoxia and compromised energy metabolism
and may be the cause of metabolic acidosis. A primary metabolic disorder should be
considered if there is no convincing secondary cause such as shock, asphyxia or cardiac
disease or in particular a difficult venepuncture. For details see page 12.
Urinary ketones (ketostix)

Ketonuria due to the ketone bodies 3-hydroxybutyrate and acetoacetate is normal during
fasting but is pathological in the fed state and in the neonate where it may indicate a
disorder of intermediary metabolism. Absence of ketones during fasting is suggestive of
a fatty acid oxidation disorder. Ketone levels measured by non-specific tests (including
ketostix) may be high due to the presence of interfering compounds. See also page 12.
2 Diagnosis and management of metabolic disorders
Other laboratory tests

Organ dysfunction caused by metabolic disorders may be recognised in routine
investigations such as blood counts, liver function tests, coagulation studies or creatine
kinase levels. Uric acid is elevated in several disorders with increased cellular turnover
or decreased urinary clearance. See also page 28.
Specific triggers of metabolic decompensation
Triggers Groups of disorders

Vomiting, fasting, infection, fever, Disorders of protein, energy or carbohydrate
vaccination, surgery, metabolism or hormone homoeostasis
(accident/injury)
High protein intake and/or protein Disorders of protein metabolism: Aminoacido-
catabolism pathies, organic acidurias, urea cycle defects,
hyperinsulinism-hyperammonaemia syndrome
Fruit, table sugar (sucrose), liquid Fructose intolerance
medicines
Lactose, milk products Galactosaemia
High fat intake Lipoprotein lipase deficiency, glycerol intolerance,
fatty acid oxidation disorders
Drugs Porphyrias, Glc-6-P-dehydrogenase deficiency
Extensive exercise Disorders of fatty acid oxidation, glycolysis,
muscle glycogenolysis, purine and pyrimidine
metabolism, respiratory chain
General clinical situations 3
General clinical situations
The metabolic emergency
In the neonate, the early clinical features of acute metabolic decompensation are almost
always non-specific; they include “unwell”, lethargy, feeding problems, vomiting,
abnormal breathing, hypotonia and seizures. Disorders of glucose, protein and fat
breakdown (intermediary metabolism) in the neonatal period typically have an
asymptomatic interval, with clinical manifestations from the second day of life onwards
(“intoxication type”), although hyperammonaemia in particular may present on day 1.
The baby's general condition will usually deteriorate rapidly despite normal or non-
specific findings in routine investigations (laboratory signs of infection, lumbar puncture,
chest X-ray, cranial ultrasound) and antibiotic therapy. The family history may reveal
siblings who died with similar clinical manifestations (“sepsis”, “SIDS”) or unexplained
disorders in other family members (progressive neurological disease, maternal PKU,
multiple miscarriages, HELLP syndrome, etc.). Consanguinity increases the risk of a
recessive disorder.
Metabolic disorders after the neonatal period may present with recurrent vomiting and
lethargy progressing to coma without focal neurological signs or typical patterns of organ
dysfunction. Initial management may follow similar principles as in neonates. Care must
be taken to identify the conditions that triggered metabolic decompensation such as
vomiting and fever or changes in the diet.
A metabolic disorder should be considered, along with other diagnoses (e.g.

infection, CNS pathology) ...
# in all neonates with unexplained, overwhelming or progressive disease particularly
after normal pregnancy and birth
# in all children with acute deterioration of the general condition and/or reduced
consciousness, particularly when preceded by vomiting, fever or fasting
# in all children with symptoms and signs of acidosis or hypoglycaemia
Appropriate diagnostic and therapeutic measures must be initiated as soon as possible

to avoid long-term damage.
Post-mortem investigations: See page 25.

Phase 1: Basic metabolic emergency investigations

& first line management
Stop intake of potentially toxic compounds (protein, fat, galactose, fructose)
Insert i.v. line and take blood samples for urgent analysis of:
$ Electrolytes, glucose, CRP, CK, ALT, AST, creatinine, urea, uric acid, acid-base
status, coagulation studies
$ Ammonia, lactate
$ Store plasma sample for amino acids, acylcarnitines etc.
$ Store filter paper card (“Guthrie” card for neonatal screening) with dried blood spots
for acylcarnitines (amino acids, possibly DNA studies)
$ Store the rest of the other samples for possible additional tests (inform laboratory)
Obtain urine sample:

$ Check colour and odour
$ Perform standard stix tests (e.g. ketone bodies, glucose, protein; pH > 5 during
acidosis % DD renal tubular acidosis)
$ Store urine sample from the acute phase for organic acids or additional metabolic
tests
If lumbar puncture is performed:

$ Store CSF (freeze immediately)
Start with 10% glucose infusion, 150 ml/kg/day (10 mg/kg/min, ~60 kcal/kg/day), with
appropriate electrolytes.
Glucose supply in this infusion is at the rate of normal hepatic glucose production
and is usually sufficient for disorders of reduced fasting tolerance such as glycogen
storage disorders or MCAD deficiency. It may not be sufficient in disorders that are
exacerbated by catabolism, e.g. organic acidurias or urea cycle defects. It may be
potentially dangerous in mitochondrial disorders (specifically pyruvate dehydroge-
nase deficiency) as a high glucose supply may enhance lactic acidosis. The benefits
of the high-glucose infusion outweigh the risks but lactate and acid-base status
should be checked regularly.
Order additional investigations as indicated, e.g. ECG, echocardiogram, cranial imaging.

Results of emergency investigations should be available within 30(–60) min. At that
stage, decide on specialist investigations and additional therapeutic measures.
Phase 2: Treatment and investigations according to the initial findings
If the emergency investigations show ...

... hypoglycaemia: See page 6
... hyperammonaemia: See page 8
... metabolic acidosis: See page 11
... elevated lactate: See page 13
... severe liver disease: See page 19
If results are inconclusive but metabolic disease remains a possibility:

$ Continue glucose infusion
$ Review the history and clinical signs. Phone regional metabolic centre for advice
$ After discussion, send samples for specialist metabolic investigations (results relevant
to the diagnosis of treatable metabolic disorders should be available within 24 [at
most 48] hrs):
– Dried blood spots for acylcarnitines and amino acids (urgent analysis)
– Plasma sample for amino acids and acylcarnitines
– Urine sample for simple metabolic tests and organic acids
$ Monitor electrolytes, glucose, lactate, acid-base status (keep sodium well above 135
mmol/l to avoid cerebral oedema)
Hypoglycaemia Glucose concentration:

1 mmol/l = 18 mg/dl
10 mg/dl = 0.55 mmol/l
Definition
Blood glucose < 2.6 mmol/l (45 mg/dl) at all ages
Consider
$ In the neonate: Evidence of non-metabolic causes?
$ History: Time since last meal (hypoglycaemia postprandial, after fasting), drugs,
erratic?
$ Examination: Hepatomegaly, liver failure or cirrhosis, small genitals,
hyperpigmentation, short stature?
$ Glucose requirements: > 10 mg/kg/min indicates hyperinsulinism (page 109) unless
there are marked losses elsewhere (e.g. urine)
$ Rule out (in the neonate): Septicaemia, severe systemic illness, small for gestational
age, maternal diabetes
Laboratory investigations during symptomatic hypoglycaemia

Adequate laboratory tests must be carried out during symptomatic hypoglycaemia to
identify the underlying cause, or else many diagnoses may be missed.
Essential
$ Free fatty acids + 3-hydroxybutyrate (serum or plasma); ketostix (urine).
A marked elevation of free fatty acids indicates active lipolysis and that the
hypoglycaemia is associated with a fasting reaction. In this situation, “normal” (low)
values of plasma ketones (3-hydroxybutyrate is sufficient) are strongly suggestive of
a disorder of fatty acid oxidation or ketogenesis. Normal values: See page 158.
$ Acylcarnitines (dried blood spots or plasma); this test is diagnostic of most (but not
all) fatty acid oxidation disorders and various organic acidurias.
$ Hormones (serum): Insulin (normal range < 2–5 mU/l when glucose < 2.6 mmol/l
[45 mg/dl]), cortisol (normal > 270 nmol/l)
$ Lactate (blood, NaF tube). Elevations may indicate liver damage or impaired
glycogenolysis/gluconeogenesis but may also be found after a seizure or difficult
blood sampling. See page 13.
$ One spare tube (serum or plasma) for anything from below or forgotten or lost
$ Organic acids (urine) ĺ various metabolic disorders that may cause hypoglycaemia
Others
$ Blood gases, blood count, CRP, electrolytes, phosphate, liver/renal function tests,
CK, uric acid, triglycerides, carnitine status, growth hormone
$ Ammonia (EDTA blood) ĺ e.g. liver damage
$ Amino acids (plasma)
$ Consider toxicological investigations (including C-peptide)
Differential diagnosis
Hypoglycaemia in premature children is frequently caused by problems of adaptation and
may not require extensive laboratory tests. The most frequent causes of persistent neo-
natal hypoglycaemia are hormonal disturbances, e.g. hyperinsulinism or hypopituitarism.
The hypoglycaemia is accompanied by low concentrations of free fatty acids and ketone
bodies due to inhibition of lipolysis. Regulatory disturbances (e.g. ketotic hypoglyc-
aemia, glycogen storage disease type III, hypopituitarism after the first year of life) result
in hypoglycaemia with particularly strong ketosis. Defects of fatty acid utilisation
(carntine shuttle, fatty acid oxidation, ketogenesis) are characterised by hypoglycaemia,
high levels of free fatty acids and low ketones during lipid catabolism. Gluconeogenesis
defects (e.g. glycogen storage disease type I) show marked hypoglycaemia with lactic
acidosis; ketone levels may be low or elevated.
As always: There are exceptions to every rule or simplification.
Ketones “normal” (low) or Free fatty acids relatively low: Hyperinsulinism,

insufficiently elevated & counterregulatory hormones, e.g. hypopituitarism
Free fatty acids greatly elevated: Disorders of fatty
acid oxidation and ketogenesis
Ketones elevated “Ketotic hypoglycaemia”, organic acidurias,
& counter-regulatory hormones (after the first year),
glycogen storage disease types III and 0
Lactate Without Organic acidurias, ketolysis defects, respiratory chain
elevated hepatomegaly defects, long-chain fatty acid oxidation disorders
(> 2 (especially LCHAD)
mmol/l) Isolated Glycogen storage diseases, gluconeogenesis defects
hepatomegaly
Liver disease Fructose intolerance, respiratory chain defects, long-
chain fatty acid oxidation disorders, tyrosinaemia type I
Treatment
$ Glucose i.v. 7–10 mg/kg/min (glucose 10%: 110–150 ml/kg/day), keep blood sugar
5.5 mmol/l (100 mg/dl)
If glucose bolus is needed: Do not give more than 200 mg/kg (glucose 20%: 1 ml/kg).
$ Await results of specialist investigations and treat accordingly
$ High glucose requirement > 10 mg/kg/min or an insulin level greater than the lower
limit of normal at times of hypoglyaecemia is abnormal and invariably means
hyperinsulinism, see page 103
$ For disorders of fatty acid oxidation and ketogenesis see page 94
Hyperammonaemia NH3 concentration: µmol/l = µg/dl x 0.59
NH3 values: Neonates: Healthy < 110 µmol/l

Sick up to 180 µmol/l
Suspect metabolic disease > 200 µmol/l
After the neonatal period 50–80 µmol/l
Suspect metabolic disease > 100 µmol/l
Blood sample: Uncuffed venous (or arterial) sample, keep on ice, analyse immediately.
Caution: NH3 concentration in tissue is 10 x higher than in blood.
False elevations of ammonia are common.
It is essential to measure ammonia early in every sick child in whom a metabolic

disease may be the underlying diagnosis. Hyperammonaemia may be missed otherwise
and the child may be deprived of efficient treatment. If it is not possible to obtain the
“perfect sample”: Measure ammonia anyway and repeat under better circumstances if
ammonia is high.
Causes
$ Urea cycle disorders (page 61): Most common cause of severe hyperammonaemia,
presenting with progressive or chronic relapsing encephalopathy. May initially be
associated with respiratory alkalosis (central effect of hyperammonaemia) but
metabolic alkalosis or acidosis may occur. Short time-span from first symptoms to
irreversible brain damage – rapid and efficient management is of utmost importance!
$ Organic acidurias (e.g. propionic aciduria; page 65) – approx. 30% of severe
neonatal hyperammonaemias: Blocked urea synthesis due to deficiency of acetyl-CoA
(required for N-acetylglutamate synthesis) and inhibition of NAGS by organic acids.
Usually associated with (lactic) acidosis at an early stage (note: Sometimes alkalosis
due to vomiting or hyperammonaemia). The ammonia concentration does not allow a
diagnostic distinction to be made between urea cycle defects and organic acidurias.
$ Severe liver failure
Note: Elevated transaminases or reduced PTT may also be found in urea cycle defects
$ Transient hyperammonaemia due to open ductus venosus, particularly in neonates
with respiratory distress syndrome – plasma-Gln/NH3 ratio < 1.6 µmol/µmol
$ Increased muscle activity during assisted ventilation, respiratory distress syndrome or
shortly after generalised seizure – NH3 values rarely above 180 µmol/l
Emergency investigations and differential diagnosis

A metabolic disorder should be strongly suspected in all term babies with NH3
> 200 µmol/l. As treatment differs for different causes of hyperammonaemia, it is
important to reach the exact diagnosis as soon as possible. The results of all laboratory
investigations must be obtained within a few hours, if necessary at night. Contact the
metabolic specialists (emergency services) by phone, send samples by courier (taxi)!
Investigations
$ Basic investigations (page 3)
$ Amino acids in plasma and urine
$ Organic acids and orotic acid in urine
$ Acylcarnitines in dried blood spots
Plasma Other features Diagnosis

citrulline
Low (usually) '' Orotic acid Ornithine transcarbamylase deficiency
Specific acylcarnitines Organic aciduria, e.g. propionic or
and organic acids methylmalonic aciduria
&-n Orotic acid Carbamylphosphate synthase deficiency,
N-acetylglutamate synthase deficiency
> 30 µM ' Orotic acid Lysinuric protein intolerance
> 50 µM &-n Orotic acid, ' lactate Pyruvate carboxylase deficiency (neonatal)
100–300 µM ' Argininosuccinate Argininosuccinic acidaemia
> 1 000 µM ' Orotic acid Citrullinaemia
Emergency management
Organise all treatment options as soon as hyperammonaemia is confirmed. Extra-

corporeal detoxification must be promptly initiated with NH3 > 500 µM. Even
conservative therapy requires frequent monitoring of ammonia and plasma amino
acids, and the patient should usually be transferred to the nearest paediatric metabolic
centre. Insert central venous catheter and arterial line.
Principles
$ Stop protein intake, reduce catabolism
$ Remove ammonia (drugs, extracorporeal detoxification)
$ Replenish urea cycle intermediates with arginine or citrulline; support mitochondrial
metabolism with carnitine in organic acidurias
$ Support urinary ammonia excretion by generous fluid intake; consider forced diuresis
First infusion (over 2 hrs)

$ Glucose 10 mg/kg/min (10% solution: 12 ml/kg/2 hrs) with appropriate electrolytes
$ Arginine hydrochloride 360 mg/kg (= 2 mmol/kg = 2 ml/kg of 1 M solution)
$ Na-benzoate 250 mg/kg (if available: Additional Na-phenylacetate 250 mg/kg or oral
[i.v.] Na-phenylbutyrate 250 mg/kg)
$ Carnitine 100 mg/kg (less when fatty acid oxidation disorder may be present)
®
$ Consider Ondansetron (Zofran ) 0.15 mg/kg i.v. bolus in the non-comatose child
(infusion can lead to nausea and vomiting)
Arginine, Na-benzoate and carnitine may be mixed in glucose 10% and administered as a
bypass to the regular infusion.
Check glucose, add insulin if necessary; check ammonia after 2 hrs.

Note: Na-benzoate and -phenylacetate (precursor Na-phenylbutyrate available for oral

administration only in most countries) provide alternative pathways of nitrogen
excretion by conjugation with glycine and glutamine, respectively. There has been
some debate whether these substances should be used for detoxification of
ammonia before the diagnosis is known because there is the theoretical risk of
intramitochondrial CoA depletion in organic acidurias. However, in many
metabolic centres these drugs are regularly used for the detoxificion of ammonia
in organic acidurias (especially propionic aciduria), without apparent adverse
effects. Na-benzoate and phenylbutyrate/-acetate are toxic in high plasma concen-
trations (above 2 mmol/l and 4 mmol/l, respectively). Measuring plasma levels of
Na-benzoate is recommended in the neonatal period, particularly in jaundiced
infants, but this analysis is not available in most centres. The risk of toxicity is
considered to be low with maintenance doses of 250 mg/kg/day but may be
relevant with higher doses. Check for high serum-Na+ and low K+ particularly
during treatment with both Na-benzoate and -phenylbutyrate (250 mg/kg Na-
benzoate or -phenylbutyrate contain 1.74 mmol or 1.35 mmol sodium,
respectively).
Extracorporeal detoxification
Start urgently if NH3 > 500 µmol/l (> 850 mg/dl). Use haemodiafiltration if available,
otherwise haemofiltration or haemodialysis. Peritoneal dialysis is not efficient. Exchange
transfusion increases the protein and ammonia load and should not be used.
Consider oral carbamyl glutamate 100 mg/kg/day in 3 doses in patients with biochemical
findings suggestive of CPS I or NAGS deficiency (acute hyperammonaemia, normal
orotic acid, absence of specific other metabolites; see page 63).
Maintenance treatment of hyperammonaemia

Maintenance infusion (over 24 hrs)
$ Arginine hydrochloride (180–)360 mg/kg (adjust according to plasma Arg levels:
Aim for 80–150 µmol/l; stop once argininaemia or lysinuric protein intolerance has
been diagnosed.
$ Na-benzoate 250 mg/kg (up to 500 mg/kg in confirmed urea cycle disorders, provided
that plasma levels can be monitored).
Na-phenylacetate/-phenylbutyrate 250 mg/kg when i.v. preparation available;
otherwise oral Na-phenylbutyrate 250–500 mg/kg/day in 3 doses when possible.
$ Carnitine 100 mg/kg/day (not required once urea cycle defect is confirmed)
$ Glucose 10–20(–30) g/kg, add insulin 0.1–1 IU/kg/hr if blood sugar > 200 mg/dl
$ Intralipid 0.5–1 g/kg after exclusion of long-chain fatty acid oxidation disorder
(up to 3 g/kg – monitor triglycerides)
$ Adequate amounts of fluids and electrolytes
$ If necessary: Antiemetic therapy with Ondansetron (Zofran 0.15–0.5 mg/kg)
!
Treatment after diagnosis: Urea cycle defects see page 62, organic acidurias see page 65.
The prognosis of a urea cycle disorder is poor if there has been prolonged coma > 36 hrs
before start of specific therapy, or more specifically, if the concentration of NH3 (µmol/l)
multiplied with the duration of coma (days) exceeds 4 000 µmol/l.
Metabolic acidosis and ketosis
Normal values: pH 7.37–7.43

PaO2 70–100 mmHg (9.3–13.3 kPa)
PaCO2 27–40 mmHg (3.6–5.3 kPa)
HCO3- (arterial) 21–28 mmol/l
Anion gap = [Na+] – [Cl- + HCO3-] 7–16 mmol/l
Metabolic acidosis is characterised by decreased pH, HCO3- and PaCO2.
Acidosis due to Typical findings
Renal loss of Normal anion gap, increased Cl-, urinary pH > 5 (with acidosis);
bicarbonate Renal Fanconi syndrome: Additional signs of renal tubular
dysfunction (' urinary glucose, reducing substances, phosphate,
amino acids)
Intestinal loss of Diarrhoea; normal anion gap, increased Cl-;
bicarbonate urinary pH may be elevated due to hypokalaemia and secondary
increase of urinary ammonium
Organic acids Increased anion gap
(e.g. lactate, ketones)
Renal causes of metabolic acidosis

Presenting feature of
$ Various forms of primary renal tubular acidosis (= RTA, various modes of
inheritance)
$ Fanconi-Bickel disease (glycogenosis type XI due to a deficiency of glucose
transporter Glut2; causes RTA, aminoaciduria, phosphaturia, glucosuria, fasting
hypoglycaemia; see page 106)
$ Lowe syndrome (oculocerebrorenal syndrome: RTA, cataracts, glaucoma, hypotonia)
$ Osteopetrosis (RTA, typical bone changes)
$ Cystinosis, see page 122
Accompanying feature of
$ Tyrosinaemia type I, see page 72
$ Hereditary fructose intolerance, see page 102
$ Glycogen storage disease type I, see page 104
$ Mitochondrial disorders, see page 87
$ Methylmalonic aciduria (chronic renal damage), see page 66
Metabolic acidosis caused by accumulation of organic anions

Acquired causes
$ Severe infections, septicaemia
$ Advanced catabolic state
$ Tissue hypoxia
$ Dehydration
$ Intoxication
Investigations: Determine causative acid(s)

$ Blood lactate
$ Blood ketones (3-hydroxybutyrate)
$ Urinary organic acids
$ Plasma amino acids
$ Carnitine status (free and total)
$ Acylcarnitines (dried blood spots)
Differential diagnosis (primary metabolic disorders)
Ketones Lactate Other Blood NH3 Suggestive diagnosis

organic glucose
acids
+–++ (n–)++ ++ variable n–' Organic acidurias (MMA, PA, IVA)
+++ n ++ variable n–' Oxothiolase deficiency
+++ n–' ++ high low Diabetes mellitus
n–++ +++ variable variable n–' Respiratory chain disorders, pyruvate
dehydrogenase deficiency
n–++ ++ variable low n Disorders of gluconeogenesis or
glycogen storage
low n–++ ( low n–' Fatty acid oxidation defects
Ketosis
Ketosis is a physiological response to fasting, catabolic state or ketogenic diet. In some
children ketosis is associated with nausea and vomiting; “ketonaemic” vomiting of
infants with normal blood sugar is rarely caused by a primary metabolic disorder.
Permanent ketosis may in rare cases indicate a ketolysis defect. Ketosis in addition to
other metabolic abnormalities is frequently found in disorders that affect mitochondrial
metabolism (particularly organic acidurias but also e.g. respiratory chain disorders). The
differential diagnosis includes diabetes mellitus. Ketonuria in the neonate is often
indicative of a primary metabolic disorder.
Ketosis with fasting hypoglycaemia due to regulatory disturbances is found as a normal

variant in infants and small children but may also indicate adrenal insufficiency or
glycogen storage diseases (GSD) type 0. Postprandial ketosis and lactic acidosis in
association with fasting hypoglycaemia and hepatomegaly may indicate GSD III or other
GSD types (see also page 104).
Elevated lactate Lactate concentration: mmol/l = mg/dl x 0.11
Normal values: Blood < 2.1 mmol/l (< 19 mg/dl)

CSF < 1.8 mmol/l (< 16 mg/dl).
Blood sample: uncuffed vein (scalp, i.v. line) or artery, relaxed child
Na-fluoride sample tube
Pyruvate analysis is not usually indicated. Measurement may be considered when lactate
is elevated to determine the lactate/pyruvate ratio (redox state, normal < 20). This
requires perchloric acid extraction (page 38).
Alanine (plasma amino acids) reflects the concentration of pyruvate (and indirectly
lactate) but is not affected by cuffing. Normal < 450 µmol/l, alanine/lysine ratio < 3.
It can be difficult to distinguish primary and secondary lactic acidaemia; the latter could
also be due to a primary mitochondrial disorder. CSF lactate should be determined
routinely when a lumbar puncture is performed in patients with neurological disease.
Secondary causes
$ Most common: The use of a tourniquet or difficulty in drawing the blood
$ Muscular activity, assisted ventilation, seizures (lactate up to 4–6 mmol/l)
$ Severe systemic disease: Central and peripheral hypoxia or ischaemia, shock, cardiac
failure, cardiomyopathy, liver or renal failure, septicaemia, diabetes mellitus, etc.
$ Any severe metabolic disease
$ Renal tubular syndrome, hyperchloraemia, urinary tract infection (lactic aciduria)
$ Drugs (biguanides); intoxication (e.g. ethanol)
$ Consider thiamine deficiency (page 153)
Metabolic causes
$ Disorders of the respiratory chain or tricarboxylic acid cycle
$ Pyruvate dehydrogenase (PDH) or pyruvate carboxylase deficiency
$ Long-chain fatty acid oxidation disorders
$ Organic acidurias, disorders of biotin metabolism
$ Glycogen storage diseases, gluconeogenesis disorders
Laboratory investigations
$ Acylcarnitine analysis will reliably detect most disorders of fatty acid metabolism
$ Ketosis is indicative of a primary metabolic disorder (inhibiton of the tricarboxylic
acid cycle); it is not found in PDH deficiency and fatty acid oxidation disorders
$ Postprandial elevation of lactate (> 20%) or ketone bodies (paradoxical ketonaemia)
may indicate PDH deficiency or respiratory chain defects; ' lactate after glucose
challenge also in glycogen storage disease types 0, III, VI
$ Postprandial fall of lactate values and fasting hypoglycaemia may indicate glycogen
storage disease type I or gluconeogenesis defects
Treatment
Treat according to the primary diagnosis. For details on the diagnosis and treatment of
primary lactic acidosis or mitochondrial disorders see page 87.
Psychomotor retardation
Many metabolic disorders cause variable, chronic brain damage and psychomotor
retardation. This may be progressive (continuous or exacerbated by acute illness),
sometimes involving loss of previously acquired skills and typically affects all areas of
development to a variable extent. The parents may report severe behavioural problems
such as hyperactivity, irritability, aggressiveness or sleep disturbances. Careful neuro-
logical examination may reveal objective anomalies, e.g. of muscle tone. Involvement of
other organs should be sought by clinical examination or additional investigations such
as abdominal ultrasound scan or skeletal X-rays. MRI, CSF analysis, EEG and neuro-
physiological tests are only indicated in severely retarded children.
Laboratory tests in isolated mental retardation without dysmorphic features

$ Basic laboratory tests (page 1)
$ Check thyroid function
$ Creatine metabolites (urine; " creatine transporter deficiency, page 99)
$ Genetic analyses, e.g. chromosomes, fragile X syndrome; consider Rett syndrome
Additional laboratory tests in mental retardation with neurological abnormalities

$ Urine: Simple tests, organic acids, glycosaminoglycans, oligosaccharides, sialic acid
$ Plasma/serum: Quantitative amino acids
$ Biotinidase activity, if not included in neonatal screening (dried blood spots)
$ Consider purines and pyrimidines (urine), glycosylation disorders (CDG, page 131)
$ Consider thiamine deficiency, page 153
Additional laboratory tests in mental retardation with dysmorphic features

$ Sterols, peroxisomal studies (very long-chain fatty acids, phytanic acids,
plasmalogens)
$ Transferrin isoelectric focusing for glycosylation studies (CDG, page 131)
$ Other genetic analyses, e.g. screening for subtelomeric deletions
Psychomotor retardation and ...

… progressive loss of skills or organomegaly: Consider lysosomal disorders, page 111
… multi-system disorder: Consider mitochondrial disorders (page 87),
peroxisomal disorders (page 124), glycosylation disorders (CDG, page 131)
… liver disease: See page 19
… progressive myopia, dislocated eye lenses: Measure total homocysteine, page 32
… cardiomyopathy: See page 16
… abnormal hair: Consider Menkes disease, page 152
… seizures: See page 15
… macrocephaly: Check urinary organic acids (glutaric aciduria type I, Canavan disease
etc.), lysosomal storage diseases. MRI is recommended as hydrocephalus must be
ruled out. One of the recently identified leukodystrophies, megalencephalic
leukodystrophy with subcortical cysts (MLC) can only be diagnosed by MRI.
Epileptic encephalopathy
Epileptic seizures occur frequently in many metabolic disorders but are particularly
common with disorders of the cerebral grey matter. All children with epilepsy and
additional symptoms such as failure to thrive, mental retardation or neurological
abnormalities should receive a metabolic work-up.
$ Basic laboratory tests (page 1)
$ Urine: Simple tests (including bed side sulphite test for sulphite oxidase deficiency,
page 77), organic acids, purines and pyrimidines, creatine metabolites
$ Plasma: Quantitative amino acids including homocysteine
$ Serum: Glycosylation studies (CDG, page 131)
$ CSF: Protein, glucose, lactate, quantitative amino acids, neurotransmitters (page 42)
– Glycine CSF/plasma ratio > 0.06: Non-ketotic hyperglycinaemia, page 80
– Glucose CSF/plasma ratio < 0.35: Glucose transport protein deficiency, page 149
– Serine CSF/plasma ratio < 0.2 in serine synthesis defects, page 79
$ Biotinidase activity (dried blood spots)
Consider
$ Neuronal ceroid-lipofuscinosis, page 123
$ Other lysosomal disorders, page 111
$ Peroxisomal disorders, page 124
$ Mitochondrial disorders, page 87
$ Choreoacanthocytosis, page 153
Try
$ Pyridoxine 100(–500) mg i.v.: Vitamin B6-responsive seizures, page 148
$ Pyridoxal phosphate 30 mg/kg oral: Pyridoxal phosphate-responsive seizures, page
148
$ Folinic acid 3 mg/kg i.v.: Folinic acid- responsive seizures, page 149
The floppy infant
Muscular hypotonia is a common symptom in metabolic disorders in which it is usually

associated with other symptoms such as lethargy or coma, seizures, neurological
abnormalities or dysfunction of other organ systems. Laboratory investigations may
identify typical metabolic derangements. Isolated muscular hypotonia is more frequently
observed in primary neuromuscular disorders or the Prader-Willi syndrome.
Investigations
$ Basic laboratory tests (page 1), electrolytes, CK
$ Urine: Simple tests, organic acids, oligosaccharides
$ Plasma: Quantitative amino acids
$ Serum: Carnitine (free and total), peroxisomal studies (page 37)
$ Dried blood spots: Acylcarnitines, biotinidase activity
Consider
$ Mitochondrial disorders (page 87), disorders of (long-chain) fatty acid oxidation and
the carnitine cycle (page 94)
$ Pompe disease (page 104), peroxisomal disorders (page 124); CDG (page 131)
$ Causes of epileptic encephalopathy, page 15
Exercise intolerance
Exercise induced pain, muscle cramps and destruction of muscle fibres may be caused by
insufficient energy supply of muscle cells.
$ Disorders of glyco(geno)lysis, e.g. muscle phosphorylase deficiency: See page 105.
$ Disorders of fatty acid oxidation, e.g. carnitine palmitoyl-transferase II: See page 95.
$ Mitochondrial disorders, page 87
$ Disorders of purine nucleotide cycle: Myoadenylate deaminase deficiency, page 141.
Enquire
$ When does pain start?
– Disorders of glyco(geno)lysis: Symptoms typically occur at start of intense
exercise; may improve after short rest (“second wind” phenomenon)
– Disorders of fatty acid oxidation: Symptoms typically occur during longer
exercise and in recovery phase
– Disorders of respiratory chain: Ability to exercise continuously compromised
$ Discolouration of urine after exercise (myoglobinuria)?
$ Other problems, e.g. haemolytic anaemia (disorders of glycolysis), Reye-like episodes
(disorders of fatty acid oxidation)?
Investigations
$ “Muscle enzymes” including CK, LDH + isoforms, aldolase, ALT/SGOT,
AST/SGPT, urea creatinine, thyroid hormones; myoglobin (urine): Elevated
during/after episodes
$ Acylcarnitines (dried blood spots)
$ Forearm ischaemia test (page 52)
Cardiomyopathy
Cardiomyopathy is an important manifestation of several metabolic disorders. It is often

dilated hypertrophic and may be associated with severe arrhythmia. Skeletal myopathy is
usually also present but may be subtle. It is important to search for additional signs of
systemic disease including hepatic or neurological dysfunction, storage disease or
metabolic derangement.
Endocardial fibroelastosis: Thickening and stiffening of the endocardium in various

conditions including metabolic disease, viral myocarditis, or “idiopathic”.
Disorder/groups Additional features (not mandatory) Age (yrs) Page

Pompe disease (infantile) Very floppy, typical ECG 0–1 105
Fatty acid oxidation Encephalopathy, fasting hypoglycaemia, 0–2 94
lactic acidosis, liver dysfunction
Mitochondrial Lactic acidosis; heart block Any age 87
Barth syndrome 3-Methylglutaconic aciduria; neutropenia 0–2 92
MPS I, II and VI Features of “storage disorder” Any age 112
Accompanying feature in:

Disorder/groups Additional features (not required) Page
Organic acidurias (e.g. propionic) Metabolic acidosis, ketosis 65
Haemochromatosis Liver disease 154
Congenital disorders of glycosylation Multi-system disease; pericardial effusion 131
Glycogen storage disorders III & IV Hepatomegaly, hypoglycaemia 104
Lysosomal disorders Cardiac involvement may be valvular and 111
may be mild or late
Chronic ischaemic heart disease e.g. homocystinuria; 77
homozygous LDL receptor deficiency 135
Nutritional deficiencies e.g. selenium, 152,
thiamine 153
$ Basic laboratory tests (page 1), repeat lactate, CK, ALT/SGOT, AST/SGPT
$ Urine: Simple tests, organic acids, glycosaminoglycans, oligosaccharides
$ Vacuolated leukocytes
$ Dried blood spots: Acylcarnitines
$ Serum: Carnitine (free and total), CDG analysis; selenium, thiamine
Consider
$ Leukocyte enzyme studies (including !-glucosidase [Pompe disease])
$ Skin biopsy for enzyme studies
$ Skeletal muscle biopsy in case of significant skeletal myopathy (histology,
histochemistry, electron microscopy, biochemical and functional studies)
$ Liver biopsy in case of significant hepatic dysfunction
$ Exceptionally: Endocardial biopsy (inflammatory changes, viral particles, signs of
mitochondrial dysfunction, lysosomal storage, accumulation of lipids or glycogen)
Dysmorphic features
Most disorders of intermediary metabolism (“small molecule disorders”) cause symptoms

only after birth since metabolic homoeostasis is maintained via the placenta.
Morphological abnormalities of prenatal (or postnatal) onset may be generated in
metabolic disorders ...
... that affect structural macromolecules, such as peroxisomal disorders and congenital
disorders of glycosylation;
... that cause progressive accumulation of metabolites, such as lysosomal disorders;
... that affect signalling pathways, such as the disorders of sterol synthesis;
... that affect cellular energy metabolism, such as pyruvate dehydrogenase deficiency.
Brain imaging may show structural abnormalities in many of these disorders, including
disturbances of neuronal migration in peroxisomal disorders or cerebral malformations in
mitochondrial disorders. In most disorders the disease course is progressive or dynamic,
pointing to a metabolic process. However, some disorders such as the Smith-Lemli-Opitz
syndrome may cause only mild dysmorphism and should be ruled out in all patients with
mental retardation and minor morphological anomalies (see page 14)
Peroxisomal disorders (page 124)

The most severe disorders of peroxisomal function (Zellweger syndrome) cause typical
facial anomalies recognised at birth: High forehead, flat and broad base of the nose,
epicanthus and abnormal ears. Skeletal abnormalities are most prominent in rhizomelic
chondrodysplasia punctata.
Lysosomal storage disorders (page 111)

Apart from rare cases of non-immune fetal hydrops, children with lysosomal disorders
often appear normal at birth (exceptions include I-cell disease). Morphological
abnormalities develop over the first months and years of life, characterised by a typical
(“coarse”) facies, skeletal changes (dysostosis multiplex, short stature), changes of skin
and hair and organomegaly.
Disorders of sterol synthesis (page 127)

Cholesterol plays an important role in the embryonal hedgehog signalling pathway.
Disturbance of this pathway may be at least partly responsible for the typical congenital
malformations seen in Smith-Lemli-Opitz syndrome (microcephaly, unusual facies,
syndactyly of toes and genital anomalies in males) and other sterol synthesis disorders.
Disorders of energy metabolism (page 87)

Dysmorphism may be present at birth in mitochondrial disorders but is usually subtle and
does not point to the diagnosis since other clinical features are more prominent. Children
with severe PDH deficiency may resemble those with fetal alcohol syndrome.
Other disorders with morphological anomalies

$ Menkes disease, page 152
$ Congenital disorders of glycosylation, page 131
$ Homocystinuria, page 77
Investigations: See page 14, psychomotor retardation and dysmorphy.

Liver disease
Manifestation patterns
Acute and chronic hepatocellular dysfunction may be associated with:
$ Failure to thrive, muscle wasting, recurrent infections
$ Encephalopathy: Lethargy progressing to coma, behavioural changes, intellectual
deterioration, pyramidal tract signs
$ Bleeding disorder: Haematemesis, epistaxis, haematoma
$ Signs of portal hypertension: Splenomegaly, ascites, shunt circulation
$ Renal dysfunction – in several metabolic disorders this is due to toxins affecting both
organs but renal dysfunction may also be the cause or the consequence of hepatic
dysfunction
Hepatomegaly
Hepatomegaly may present as obvious abdominal distension or may be an incidental
finding. Causes include increased cell size due to storage of various substances (e.g. fat,
glycogen, lysosomal substrates, iron), inflammation/oedema, tumours (e.g. in tyrosin-
aemia type I), venous congestion or biliary obstruction.
$ Consistency
– Soft (e.g. glycogen storage disease)
– Firm (e.g. lysosomal storage disease)
– Hard and irregular (cirrhosis, e.g. in tyrosinaemia type I)
$ Associated with splenomegaly?
– Evidence of portal hypertension (cirrhosis) causing splenomegaly?
– Evidence of generalised storage disorder? Liver cell function is normal in many
lysosomal storage disorders.
– Evidence of malignancy (leukaemia)?
$ Evidence of metabolic disturbances or other abnormalities?
– Hypoglycaemia (e.g. glycogen storage disease)
– Renal disease (tyrosinaemia type I, Fanconi-Bickel disease)
– Bleeding diathesis (tyrosinaemia type I)
Hepatomegaly may be a presenting feature in children with chronic hepatocellular

dysfunction of various aetiologies (e.g. !1-antitrypsin deficiency, Wilson disease).
Cholestasis
The usual presenting feature of cholestasis is jaundice or pruritus. It may be due to
hepatocellular dysfunction or intrahepatic or extrahepatic obstruction of bile ducts.
Babies and infants with cholestasis require urgent referral to a specialist. It may be
associated with markedly increased serum cholesterol and xanthomata. Anicteric
cholestasis or elevated transaminases and AP with normal GGT may be found in
disorders of bile acid synthesis or secretion, as well as in conditions characterised by
biliary hypoplasia, e.g. Alagille syndrome. Cortisol deficiency may present as cholestasis
and hypoglycaemia.
Investigations (immunological and infectious causes not included)

General laboratory tests
$ Routine laboratory tests including whole blood count, glucose, renal function tests,
urea, creatinine, uric acid, CK, phosphate
$ Basic metabolic laboratory tests (page 1)
Liver function tests

$ Aminotransferases (ALT/SGOT, AST/SGPT) % hepatocellular injury
$ Gamma-glutamyl transpeptidase (GGT) % cholestasis > hepatocellular injury
$ Alkaline phosphatase (AP) % cholestasis
$ Total bile acids % cholestasis
$ Bilirubin (conjugated, unconjugated)
$ Synthetic functions: Albumin, prealbumin, coagulation studies, clotting factors
(increased prothrombin time due to nutritional vitamin K deficiency should be
corrected within a few hours after vitamin K administration)
$ Lipid analyses: Triglycerides, cholesterol
Additional investigations
$ Amino acids (plasma) (note: Elevated tyrosine may be found in hepatocellular
dysfunction of any cause and does not necessarily indicate tyrosinaemia type I)
$ Organic acids (urine) (specifically check for succinylacetone)
$ Acylcarnitine profile (dried blood spot), carnitine status (serum)
$ Galactose, Gal-1-phosphate, GALT activity
$ Iron and ferritin
$ Copper and coeruloplasmin (in children older than 4 yrs of age)
$ !1-Antitrypsin (!1-AT) concentration and phenotype (see also page 153)
$ Sweat test (cystic fibrosis)
$ Alpha-fetoprotein (AFP)
$ Bile acids, differentiated (urine)
$ Consider CDG, lysosomal studies
$ Consider coeliac disease (anti-gliadine and/or anti-endomysium antibodies,
transglutaminase)
$ Hepatopathy after introduction of fructose % hereditary fructose intolerance
$ Renal disease % galactosaemia, tyrosinaemia, hereditary fructose intolerance
$ Storage disease % lysosomal/glycogen storage disorders
$ Neuromuscular disease % peroxisomal/mitochondrial/glycogen storage disorders,
CDG, Wilson disease
$ Hemolytic anaemia %))Wilson disease, fructose intolerance
$ Cataract % galactosaemia, peroxisomal/lysosomal disorders, cerebrotend. xanth.
$ Fetal hydrops: See page 26
Neonatal liver failure

Disorder Clinical features Page
Mitochondrial hepatopathy, Muscular hypotonia, multi-system disease, 87
often mtDNA depletion encephalopathy, ' lactate
Neonatal haemochromatosis Hepatocellular necrosis, cirrhosis; '' ferritin, 155
'' AFP; transaminases may be low
Galactosaemia Onset after milk feeds; jaundice, renal disease 102
Fatty acid oxidation disorders (Cardio)myopathy, hypoglycaemia, ' lactate 94
Urea cycle disorders '' Ammonia 61
Niemann Pick type C Jaundice, hypotonia, hepatosplenomegaly 121
Glycosylation disorders Hepatomegaly, hepatocellular dysfunction, 131
(CDG, e.g. type Ib) protein losing enteropathy, multi-system disease
Rarely: !1-Antitrypsin deficiency, bile acid synthesis disorders
Severe neonatal jaundice

!1-Antitrypsin deficiency & !1-Antitrypsin 154
Niemann Pick type C Hypotonia, hepatosplenomegaly 121
Galactosaemia Onset after milk feeds; renal disease 102
Bile acid synthesis disorders Cholestatic jaundice, malabsorption 130
Peroxisomal disorders Severe hypotonia, areactivity, seizures, cataract, 124
(including Zellweger) dysmorphic and skeletal abnormalities
Mevalonic aciduria Hepatosplenomegaly, lymphadenopathy, anaemia 128
Tyrosinaemia type I Severe coagulopathy, renal disease, ' AFP 72
Crigler-Najjar Severe neonatal jaundice, kernicterus 155
Rotor, Dubin-Johnson Jaundice, normal liver function tests 155
Progress. familial intrahepatic Cholestasis of hepatocellular origin; GGT may be 155
cholestasis (including Byler) normal
Alagille syndrome Typical facies, other morphological anomalies 156
Other causes: cystic fibrosis, hypothyroidism
Hepatomegaly + hypoglycaemia
Glycogen storage disease I Hepatocellular dysfunction, large kidneys, 104
''' triglycerides, ' urate, ' lactate
Glycogen storage disease III Short stature, skeletal myopathy 105
Fanconi-Bickel disease Tubulopathy, glucose/galactose intolerance 106
Disorders of gluconeogenesis ' Lactate 103
Other causes of neonatal hypoglycaemia (see page 6)
Hepatosplenomegaly in infancy
Lysosomal storage disease Other symptoms and signs of generalised storage 111
Tangier disease Polyneuropathy, orange tonsils, corneal clouding 138
Hepatic cirrhosis
– !1-Antitrypsin deficiency 154
– Glycogen storage dis. IV 105
– Tyrosinaemia type I 72
Isolated hepatomegaly may be due to any disorder causing chronic hepatic dysfunction as
well as a range of rare disorders.
Isolated splenomegaly may be indicative of a lysosomal storage disorder; see page 111.
Infantile cholestatic jaundice

Hereditary fructose Symptoms after fructose intake: Hypoglycaemia, 102
intolerance renal disease, failure to thrive, ' urate
Bile acid synthesis disorders Cholestasis may be anicteric; malabsorption 130
Mitochondrial hepatopathy Myopathy, multi-system disease, ' lactate 87
Progress. familial intrahepatic Pruritus, hepato(spleno)megaly, progr. cirrhosis; 155
cholestasis (including Byler) ' transaminases, ' AP, GGT may be normal!
Alagille syndrome Typical facies, eye anomalies, cardiac defect, 156
vertebral anomalies; dominant inheritance
Infantile acute or chronic hepatic dysfunction

Mitochondrial hepatopathy, Myopathy, multi-system disease, ' lactate 87
Pearson syndrome
Tyrosinaemia type I Jaundice, severe coagulopathy, renal disease, 72
cirrhosis; ' AFP
Galactosaemia Jaundice, failure to thrive, renal disease, cataract; 102
later: cirrhosis
Fatty acid oxidation disorders (Cardio)myopathy, hypoglycaemia 94
including carnitine transporter
deficiency
Reye-like illness (no jaundice): See page 24
Chronic hepatitis or cirrhosis in older children

Wilson disease Neurological and renal disease, corneal ring 151
Haemochromatosis Hepatomegaly, cardiomyopathy, diabetes 155
mellitus, diabetes insipidus, hypogonadism
!1-Antitrypsin deficiency Failure to thrive; & !1-antitrypsin 154
Tyrosinaemia type I Coagulopathy, renal disease, ' AFP 72
Hereditary fructose Symptoms after fructose intake: Hypoglycaemia, 102
intolerance renal disease, failure to thrive, ' urate
Transaldolase deficiency Hepatosplenomegaly, cirrhosis (single patient) 107
Cystic fibrosis Failure to thrive, recurrent airway infections
Coelic disease Failure to thrive, diarrhoea, small stature
Reye-like syndrome
Reye syndrome is characterised by acute hepato-encephalopathy, usually complicating an

infection. It is caused by acute mitochondrial dysfunction of varying aetiology. Reye
syndrome in the narrow sense (caused by salicylates) has become rare. Inborn errors of
metabolism are now the most likely cause of “Reye-like” syndrome.
Triggers: Salicylates, antiemetics, valproate, “idiopathic”
Clinical: Vomiting, lethargy, increasing confusion % coma, seizures, decerebration,
respiratory arrest
Bioch.: Hyperammonaemia, hypoglycaemia, metabolic acidosis, liver failure, ' fatty
acids, dicarboxylic aciduria
Histol.: Swollen hepatocytes, panlobular microvesicular fat deposition (steatosis);
electron microscopy: “Typical” mitochondrial abnormalities
Enzymes: Decreased activities of various mitochondrial enzymes, normal activities of
cytosolic enzymes
DD: Metabolic disorders: Urea cycle defects, fatty acid oxidation and ketogenesis
defects, mitochondrial disorders, organic acidurias, gluconeogenesis defects,
hereditary fructose intolerance
Diagn.: Basic metabolic investigations, organic acids, orotic acid, carnitine status,
acylcarnitines, amino acids in plasma and urine, basic mitochondrial studies.
Consider additional biochemical, enzymatic or molecular studies.
Sudden unexpected death (in infancy)
Sudden infant death syndrome (SIDS) is defined as sudden cardiac and respiratory arrest
(usually during sleep) for which no cause is found. The aetiology is multifactorial.
Metabolic disorders (including fatty acid oxidation disorders, mitochondrial disorders,
organic acidurias, gluconeogenesis disorders, fructose intolerance) have been found only
in a small proportion of victims who often had previous clinical abnormalities such as
hypotonia, psychomotor retardation, seizures or hepatomegaly. Death may have been pre-
cipitated by gastroenteritis and these cases should not, by definition, be classified as
SIDS.
Investigations
$ Forensic studies
$ Basic post-mortem investigations (see page 25): Organic acids (urine), amino acids
(plasma, CSF), acylcarnitines (blood spots, bile, serum)
$ Store EDTA blood and fibroblasts for specific mutation or enzyme enzyme studies,
depending on the results of forensic studies (e.g. fatty liver) and basic investigations.
Screening tests of asymptomatic siblings are unlikely to be productive if no specific
diagnosis has been determined after adequate evaluation.
ALTE (acute life-threatening event)

Metabolic investigations after a SIDS-like episode that is survived should include basic
laboratory tests (page 1) and acylcarnitines (blood spots). Additional investigations such
as amino acids (plasma), organic acids and mitochondrial studies should be considered.
Post-mortem investigations
If a child (suddenly) dies of an unkown, possibly genetic disease, it is essential to collect

representative post-mortem samples and discuss their analysis with a metabolic
specialist. Without diagnosis, genetic counselling of the parents and reliable risk assess-
ment for future children is not possible.
Samples
The following samples should be collected and stored for post-mortem analyses if a
genetic disorder is suspected but specific metabolic investigations have not yet been
performed:
$ Serum and plasma (centrifuge several ml immediately, freeze in separate fractions)
$ Dried blood spot (on filter paper card)
$ Urine (freeze immediately – consider bladder wash with NaCl)
$ Bile (spot on filter paper card for acylcarnitine analysis: Bile contains particularly
high levels of acylcarnitines and may be more useful than blood if available)
$ DNA (3–10 ml EDTA whole blood, if necessary freeze without centrifuging)
$ Culture fibroblasts (skin biopsy, may be obtained up to 24 hrs post mortem [or even
later] and stored 1–2 days at ambient temperature in culture medium or 0.9% NaCl –
do not freeze!)
$ Consider CSF (several 1 ml fractions, freeze immediately, if possible at –70°C)
$ Consider vitreous fluid (freeze immediately)
Collect blood and urine samples prior to expected death.

Discuss investigations that may be indicated with the laboratory/metabolic specialist.
Biopsies
Fine needle biopsies should be considered before death since histological and enzymatic
mitochondrial studies in post-mortem tissues are almost uninterpretable (if necessary,
muscle biopsies may be obtained up to 1 hr post mortem). The acquisition of open organ
biopsies (see page 39) depends on the clinical picture and is only indicated in exceptional
cases. It should be discussed with the laboratory/metabolic specialist (samples are partly
frozen immediately at –70°C or in liquid nitrogen, partly to be stored in glutaraldehyde
for electron microscopy).
$ Muscle (skeletal, consider heart): > 500 mg (% DNA, histochemistry, immuncyto-
chemistry, analyses of energy metabolism; see page 89)
$ Liver > 200 mg (% histochemistry, enzyme studies)
Basic investigations
$ Amino acids in plasma (and CSF)
$ Organic acids in urine
$ Acylcarnitines from blood and/or bile spotted on a filter paper card
Note: Autolysis during the process of dying causes the intracellular fluid to mix with
extracellular fluid. Huge misleading changes of plasma metabolites may be
encountered.
Fetal hydrops
Fetal hydrops is the end stage of various conditions leading to the accumulation of fluid
in fetal tissues and body cavities. It frequently affects the whole body but in some
conditions may be restricted to certain compartments such as the abdomen (ascites). It is
defined as “immune” (due to blood cell incompatibility) or “non-immune” and is most
frequently caused by cardiovascular disease (up to 25% of cases), chromosomal disorders
(> 10%), thoracic anomalies (up to 10%), anaemia (5–10%) and various other genetic
and non-genetic condition. Inborn errors of metabolism are found only in a small
proportion of cases. Metabolic investigations should be considered after detailed
ultrasound examination, tests on maternal blood and invasive fetal testing (chromosomes,
blood count, evidence of infection, haematological disorders etc.) failed to reveal a
diagnosis.
Metabolic disorders associated with fetal hydrops

$ Lysosomal disorders
– Mucopolysaccharidoses types VII (Sly), I, IVa
– Sialidosis, mucolipidosis II (I-cell disease)
– Sphingolipidoses (galactosialidosis, Niemann Pick A, Gaucher, Farber,
GM1 gangliosidosis, multiple sulphatase deficiency)
– Lipid storage disorders (Niemann-Pick C, Wolman)
– Sialic acid storage disease
$ Sterol synthesis disorders
– Smith-Lemli-Opitz syndrome
Greenberg dysplasia
– Mevalonic aciduria
$ Peroxisomal disorders (Zellweger)
$ Glycogen storage disease type IV (Andersen)
$ Glycosylation disorders (CDG)
$ Congenital erythropoietic porphyria
$ Primary carnitine deficiency
$ Mitochondrial disorders, fumarase deficiency
$ Neonatal haemochromatosis
$ Any cause of severe cardiomyopathy
Unusual clinical observations
Urine and body odour
Odour Substance Disorder/Origin

Animal-like, mouse- Phenylacetate Untreated phenylketonuria, phenyl-
like butyrate treatment
Maple syrup, “Maggi” Sotolone Maple syrup urine disease
Acrid (sweaty feet) Isovaleric acid Isovaleric aciduria, glutaric aciduria II
Male cat urine 3-OH-isovaleric acid 3-Methylcrotonylglycinuria, multiple
carboxylase deficiency
Cabbage 2-OH-butyric acid Tyrosinaemia type I,
Rancid butter 2-Oxo-4- Tyrosinaemia type I
methiolbutyric acid
Sulphur Hydrogen sulphide Cystinuria
Methionine Tyrosinaemia type I, cirrhosis
Fish-like Trimethylamine, Trimethylaminuria, dimethylglycinuria
dimethylglycine
Discolouration of urine or nappy/diaper
Colour Substance Disorder/Origin Confirmation

Brown or Homogentisic acid Alkaptonuria Urinary organic acids
black (may be pink/red)
Met-haemoglobin Myoglobinuria Dipstick (see page 16,
exercise intolerance)
Haemoglobin Haemoglobinuria Dipstick, blood picture
Melanin Melanotic sarcoma
Red Erythrocytes Haematuria Microscopy
Porphyrins Porphyrias (not acute See page 150
intermittent porphyria)
Various Food colouring, red beet, History
(most common) blackberries, drugs (e.g.
laxatives)
External bacteria Red diaper syndrome Cloth nappies, > 24 hrs
Orange sand Urate Hyperuricosuria; Uric acid in blood and
(or bright red) physiological urine; see also page 140
Green-blue Indigotin Tryptophan Urine amino acids
malabsorption (Hartnup disease)
Biliverdin Obstructive jaundice Serum bilirubin
Methylene blue Ingestion, treatment History
Unusual laboratory findings
Unexpected findings in “routine” laboratory tests require critical evaluation. Particularly

in patients with unusual and unexplained symptoms or clinical signs, they may be
indicative of metabolic disease and can help to direct specific diagnostic investigations.
The following table is not fully comprehensive.
Finding Indicative of (selection)

Anaemia (macrocytic) Disturbances in cobalamin and/or folic acid metabolism
Reticulocytosis Glycolysis defects, disorders of the #-glutamyl cycle
Vacuolised lymphocytes Lysosomal storage disorders, juvenile NCL
' Alkaline phosphatase Bile acid synthesis defects, hypoparathyroidism
& Cholesterol Sterol synthesis defects, lipoprotein disorders, glycosylation
disorders, peroxisomal disorders
' Triglycerides Glycogen storage disorders, lipoprotein disorders
' CK Dystrophinopathies, fatty acid oxidation disorders, glycogen
storage disorders, glycolysis disorders, muscle AMP-
deaminase deficiency, mitochondrial disorders
& Creatinine Creatine synthesis disorders
' !-Fetoprotein (AFP) Tyrosinaemia type I, hepatoblastoma, neonatal
haemochromatosis, viral hepatitis, ataxia telangiectasia
' Uric acid Glycogen storage disorders (including Fanconi-Bickel
disease), fructose intolerance, disorders of purine
metabolism, fatty acid oxidation defects, mitochondrial
disorders
& Uric acid Disorders of purine metabolism, molybdenum cofactor
deficiency
' Iron, transferrin Haemochromatosis, peroxisomal disorders
' Copper Peroxisomal disorders, Wilson disease (urine, liver)
& Copper, Wilson disease (serum), Menkes disease,
coeruloplasmin acoeruloplasminaemia
Hypo(para)thyroidism Mitochondrial disorders, CDG
Low CSF glucose Glucose transport protein 1 (GLUT1) deficiency
Acanthocytosis
The appearance of spiculated erythrocytes in a peripheral blood smear or electron micro-
scopy may be caused by changes in the lipid composition or structure of the red blood
cell membrane. Two basic types are distinguished, echinocytes (burr cells) that have a
serrated outline with small, uniform projections, and acanthocytes (spur cells) with few
irregular spicules of varying size. Echinocytes and acanthocytes may be caused by a
variety of conditions including advanced uraemia, severe hepatocellular damage,
anorexia nervosa, hypothyroidism, vitamin E deficiency or splenectomy; echinocytes are
also common in (premature) neonates. Acanthocytes may be elicited by a blood dilution
test: Dilute patient and control samples 1:1 with normal saline, prepare smear, fix after
5 min – acanthocytosis is indicated by > 15% acanthocytes.
Diagnosis Clinical features Age of onset Page
Abetalipoprotein- Diarrhoea, fat malabsorption, vitamin Neonatal 138
aemia deficiencies, neurological abnormalities, period
ataxia, low cholesterol and triglycerides
Wolman disease Diarrhoea, failure to thrive, hepatospleno- Neonatal 121
megaly, adrenal calcifications period
Choreo- Progessive neurological symptoms, chorea, Adolescence 153
acanthocytosis epilepsy, dementia or adult life
McLeod phenotype, Little or no reaction with various antisera in Adult life 153
McLeod syndrome the Kell blood group system; somtimes (neurological
progressive neurological symptoms, chorea symptoms)
Special metabolic investigations are not required in ...
$ Isolated moderate psychomotor delay

$ Moderate failure to thrive
$ Frequent infections
$ Isolated delay in speech development in early childhood
$ Occasional seizure, e.g. during fever
$ Healthy sibling of a previously asymptomatic infant who died of SIDS
An important factor in the evaluation of symptoms is their isolated appearance, i.e. the
lack of additional neurological and/or systemic abnormalities.
Special metabolic investigations
Genotype Different mutations Enzymatic, metabolic and

clinical phenotypes of meta-
Interaction of mutations
Somatic mosaic
bolic disorders are influenced
Variable X-Inactivation by a wide range of factors.
Gene therapy The optimal level at which ab-
mRNA processing normalities can be recognised
Cellular protein synthesis and processing differs between disorders. In-
Cofactor concentration
Enzymatic
vestigations should generally
Enzyme replacement therapy be as close as possible to the
phenotype
Metabolic stress clinical phenotype: enzyme
Substrate intake (diet) studies (when possible) are
Substrate removal (renal) often more useful than
Primary and secondary deficiencies
Pharmacological modifications
molecular studies. External
Metabolic factors that influence the con-
phenotype centrations of key metabolites
Transport between organs (e.g. fasting, food intake etc.)
Modification of additional risk factors must be taken into conside-
Symptomatic therapy
Clinical
ration, and specific function
phenotype tests may be required to iden-
tify diagnostic abnormalities.
Simple metabolic urine tests
Reducing substances in urine

Method: Test tablets (e.g. Clinitest®, Bayer)
Detects: Any reducing substances, particularly sugars
Substance Disorder/origin
Galactose Classical galactosaemia, galactokinase deficiency,
severe liver disease (secondary galactose intolerance),
Fanconi-Bickel disease
Fructose Fructose intolerance, essential fructosuria
4-OH-Phenylpyruvate Tyrosinaemia types I and II
Homogentisic acid Alcaptonuria
Xylose, arabinose Pentosuria, arabinosuria
Glucose Diabetes mellitus, Fanconi syndrome
Oxalic acid (massive) Hyperoxaluria
Salicylates, ascorbic acid Drugs
Uric acid Hyperuricosuria
Hippuric acid Na-benzoate treatment of hyperammonaemia, malabsorption
Special metabolic investigations 31
Nitroprusside test (Brand reaction)

Method: 0.5 ml urine + 200 µl 5% Na-cyanide
Detects: Sulphur-containing acids (disulphides)
False positive result may occur in severe ketosis
Substance Disorder/origin
Cystine Cystinuria, hyperargininaemia,
generalised hyperaminoaciduria
Homocystine Classical homocystinuria, cobalamin deficiencies,
cystathioninuria (bacterial in urinary tract infections)
Glutathione Gammaglutamyl transaminase deficiency
Drugs N-Acetylcysteine, penicillamine, captopril, ampicillin and
others
Sulphite test
Method: Dipstick (e.g. Merckoquant® 10013, Merck), fresh urine at the bedside
Diagn.: Sulphite oxidase and molybdenum cofactor deficiencies (particularly test
early-onset epileptic encephalopathy)
Positive result may be caused by various sulphite-containing drugs
Amino acids (AA)
Amino acids are best analysed by ion exchange chromatography although individual
amino acids can be reliably quantitated by tandem mass spectroscopy. Qualitative
analysis in urine by thin-layer chromatography, paper electrophoresis, etc. is only rarely
indicated in the modern practice of metabolic medicine.
Indications
$ Selective metabolic screening (plasma)
$ Hyperammonaemia (plasma + urine; if emergency phone laboratory!)
$ Suspected aminoacidopathy (plasma; if emergency phone laboratory!)
$ Suspected disorder of energy metabolism (plasma, metabolic profiling)
$ Renal disorders – nephrolithiasis, Fanconi syndrome (plasma + urine)
$ Positive nitroprusside test (urine)
$ Epileptic encephalopathy (plasma + CSF, obtain samples at the same time)
$ Control of protein restricted diet (plasma, fasting)
Samples
Plasma: Minimum 0.5 ml, EDTA or heparin tube; serum possible. Obtain sample in
the morning (fasting) or 4–6 hrs after last meal, centrifuge immediately,
ship on dry ice if possible. Alternative for individual amino acids: Dried
blood spot on filter paper card.
Send emergency samples by courier (taxi).
Shipping of EDTA/heparin whole blood within 24 hrs is acceptable but not
recommended for the analysis of selected amino acids (Phe, Tyr, Ala, Val,
Leu, Ile; e.g. control of therapy in PKU).
Urine: Minimum 5–10 ml, preserve with 2 drops of chloroform, or keep frozen
CSF: Minimum 0.5 ml. If blood-stained: Unusable; if slightly blood-stained:
Centrifuge and inform lab. Send CSF + plasma samples together on dry ice.
Specific findings (plasma)

$ ' Gln (+ Ala): Hyperammonaemia;
Gln/NH3 < 1.6 µmol/µmol: Transient neonatal hyperammonaemia; liver bypass
$ Ile < 25 µmol/l: Protein deficiency (e.g. dietary overtreatment)
$ ' Ala, Pro; Ala/Lys ratio > 3: Disturbance of energy metabolism (' pyruvate)
$ Fischer ratio (Val + Leu + Ile)/(Phe + Tyr) < 2: Liver failure with risk of hepatic
encephalopathy
$ ' Cit: Renal disease; & Cit: Chronic bowel disease
Caution
$ Values depend on metabolic state (reference values 4–6 hrs after last meal):
– Postprandial: ' Essential AA (Lys, Phe, Tyr, Val, Leu, Ile, Gln, Cit), etc.
– Prolonged fasting: ' Branched chain AA (Val, Leu, Ile))& other AA
$ Nonspecific changes (plasma):
– Haemolysis, delayed centrifugation: & Arg; ')Asp, Glu, Orn, Tau, etc.
– Shipping at room temperature:)& Gln, Asn, Cys, Hcy; ')Glu, Asp
$ Tryptophan requires a special analytical method, GABA and Hcy require special
sample handling as well as special analytical methods (see below)
Homocysteine (Hcy)
Plasma for the analysis of total Hcy must be centrifuged immediately.
Normal values (fasting): Children < 10 yrs: 3.5–9 µmol/l; > 10 yrs: 4.5–11 µmol/l;
women pre-menopausal 6–15 µmol/l; post-menopausal 6–19 µmol/l; men 8–18 µmol/l.
Free GABA
Amino acid analysis determines total GABA, which is composed of physiologically
active free GABA as well as variable amounts of homocarnosine. Only major elevations
such as in GABA transaminase deficiency can be detected. To determine free GABA,
plasma or CSF must be frozen immediately and shipped on dry ice (special analytical
method).
Normal values: Plasma: 120–150 nmol/l.
CSF: Age < 1 yr: 20–40 nmol/l; > 1 yr: 20–150 nmol/l
Organic acids (OA)
Organic acids are analysed in urine, only in exceptional circumstances in other body
fluids. The method of choice is gas chromatography-mass spectroscopy (GC-MS); quan-
titation of specific OA is possible with stable isotope dilution assays.
Indications
If emergency phone laboratory!
$ Selective metabolic screening
$ Unexplained metabolic crisis (metabolic acidosis ' lactate, high anion gap,
hypoglycaemia, ketonaemia, neonatal ketonuria, hyperammonaemia, cytopenia, etc.)
$ Clincal features of systemic intoxication
$ Suspected organic aciduria, aminoacidopathy
$ Suspected fatty acid oxidation defect
$ Suspected disorder of energy metabolism
$ Undiagnosed hepatopathy
$ Investigation of neurological or neuromuscular disorders
$ Epileptic encephalopathy
$ Multi-system disorder, particularly in case of fluctuating/progressive symptoms
$ Unexplained mental retardation with neurological abnormalities
Special indications
(discuss with laboratory)
$ Quantitation of individual OA in urine/plasma for the exclusion of specific disorders
or control of therapy, for example:
– Glutaric acid + 3-hydroxyglutaric acid (glutaric aciduria type I)
– Methylmalonic acid (apoenzyme and cobalamin defects)
– 4-Hydroxybutyric acid (SSADH deficiency)
– Oxalic acid and glycolic acid (hyperoxaluria 1)
– N-Acetylaspartic acid (Canavan disease)
– Succinylacetone (tyrosinaemia type I)
$ OA in CSF: “Cerebral organic acidaemias”
$ OA in plasma, CSF or vitreous fluid when no urine sample can be obtained, e.g. post
mortem
$ Separation of optical isomers (D,L-2-hydroxyglutaric acids; D,L-glyceric acids)
Samples
Urine: Random (morning) sample, 10–20 ml (volume depends on creatinine concentra-
tion: more urine required when creatinine level is low); shipment at room temperature
(preservation with 2–3 drops of chloroform) or preferably on dry ice.
Emergency samples by courier (taxi)!
Plasma, CSF, vitreous fluid: Minimum 1 ml, freeze immediately, shipment on dry ice.
Carnitine analyses
Acylcarnitine analysis by tandem mass spectroscopy is the method of choice for the
diagnosis of the classical organic acidurias and fatty acid oxidation disorders in neonatal
and selective screening. When coupled with amino acid analysis by tandem MS, it allows
the rapid recognition of the majority of treatable metabolic disorders that present with
acute crises. This method should therefore be available for emergency analyses in all
metabolic centres. Long-term acylcarnitine monitoring may be useful for some disorders.
Acylcarnitine analysis may miss the carnitine transporter defect for which exact determi-
nation of free and total carnitine (carnitine status) in serum and urine is necessary. The
carnitine status is also used for monitoring carnitine treatment as quantification by
tandem MS is not usually sufficiently accurate.
Acylcarnitines (differentiation)
Indic.: Neonatal screening; diagnosis of organic acidurias or fatty acid oxidation
disorders; hypoglycaemia
Method: Electrospray tandem-MS or fast atom bombardment tandem-MS
Sample: Dried blood spot (filter paper card: neonatal screening card, “Guthrie” card),
plasma, bile
Findings: Diagnostic elevation of specific acylcarnitines (see page 55)
Carnitine status (total carnitine, free carnitine, acylcarnitine)

Indic.: Suspected disorder of intermediary metabolism with accumulation of CoA-
esters, primary and secondary carnitine deficiency, monitoring of treatment
Method: Radiochemical
Sample: 1 ml serum or plasma; 5 ml urine
Carnitine Acylcarnitine Urinary carnitine

differentiation
Total Free Acyl- Free Acyl-
(dried blood)
bound bound
Fasting N & '
CT deficiency && &&& && & All carnitines N-'
CPT1 deficiency N-' && & C2–C18
CAC/CPT2 deficiency; N-& & ' Specific '
FAO disorders
HMCM deficiency * * * N
SCOT deficiency N-& N
Organic acidurias* & ' Specific '
Resp. chain disorders N-& N-& N-& N
*Only some organic acidurias; CT = carnitine transporter; CPT = carnitine palmitoyl-
transferase; CAC = carnitine acylcarnitine carrier; FAO = fatty acid oxidation; HMCM =
mitochondrial HMG-CoA synthase; SCOT = succinyl-CoA:3-oxoacid transferase
Other special metabolic investigations
International quality control networks (e.g. ERNDIM/CAP) have been established for
various special metabolic investigations including amino acids and organic acids.
However, participation is generally voluntary (enquire with laboratory).
Bile acids
Indic.: Suspected bile acid synthesis defect (see page 129), peroxisomal disorder (see
page 124)
Method: FAB-(fast atom bombardment)-MS/GC-MS, electrospray tandem MS
Sample: 5 ml urine or 2 ml bile fluid
Free fatty acids (FFA) and 3-hydroxybutyrate

Indic.: Hypoglycaemia, fasting test
Method: Photometric
Sample: 1 ml serum/plasma, shipment on dry ice (to avoid lipolysis)
Normal: Non-fasting: FFA and 3-hydroxybutyrate low (< 400 µmol/l).
Fasting: both elevated up to 3–4 mmol/l, see page 158
Galactose (Gal) and galactose metabolites

Indic.: Suspected disorder of galactose metabolism (see page 101); see also page 53
(neonatal screening)
Method: Variable, discuss with laboratory
Sample: Dried blood spots for galactose concentration und enzyme studies;
EDTA whole blood for Gal-1-phosphate, enzyme studies, DNA studies;
consider plasma für galactose, urine for galactitol
Discuss with laboratory; if in doubt store dried blood spots + 2 ml EDTA
whole blood at room temperature (up to 48 hrs).
Findings: – Galactose (plasma, dried blood spots); pathological if > 10 mg/dl (0.55 mM)
– Galactose-1-phosphate (erythrocytes); pathological if > 0.5 mg/dl (19 µM)
– Galactitol (urine); pathological if > 10 mmol/mol creatinine
– Enzyme studies (erythrocytes): GALT, galactokinase, epimerase
– Mutation studies (EDTA whole blood)
Glutathione and metabolites

Indic.: Suspected disorder of the "-glutamyl cycle (see page 81)
Method: HPLC
Sample: 3 ml EDTA whole blood, centrifuge, remove and freeze plasma. Deproteinise
erythrocyte fraction with 5% sulphosalicylic acid (ratio approx. 1:1, e.g.
300 µl to 200 µl), shake/vortex thoroughly (until homogenous brown colour),
centrifuge twice at 5 000 g, remove and freeze clear supernatant. Send plasma
and deproteinised erythrocytes (unequivocal labelling) on dry ice.
Glycosylation studies (CDG analysis)

Indic.: Suspected disorder of protein glycosylation, CDG (see page 131)
Method: Transferrin electrophoresis/isoelectric focusing, tandem-MS, capillary
electrophoresis
Sample: 0.5–1 ml serum
Findings: Different subtypes correspond to different enzyme deficiencies; abnormal
glycosylation patterns (secondary changes) also in alcoholism, galactosaemia,
fructose intolerance, hepatitis C, etc.
Lysosomal studies
Glycosaminoglycans (GAG; mucopolysaccharides)
Indic.: Suspected lysosomal storage disease/mucopolysaccharidosis (see page 114)
Method: Screening: GAG quantitation (“DMB test”)
Specific analysis: Electrophoretic separation of different GAGs
Sample: 10–20 ml urine without additives
Findings: GAG elevation – may be mild/borderline in MPS III (Sanfilippo) and IV
(Morquio) but differentiation by electrophoresis can identify the pathological
excretion of heparan/keratan sulphate and is therefore always recommended.
Oligosaccharides, free neuraminic acid (sialic acid)

Indic.: Suspected lysosomal storage disease/oligosaccharidosis (see page 117)
Method: Thin-layer chromatography with various staining reagents
Sample: 10–20 ml urine, shipment frozen or preserved with 2–3 drops of chloroform
Findings: Reliable diagnosis of: Pompe disease, GM1 and GM2 gangliosidoses, !-
mannosidosis and !-mannosidosis, fucosidosis, Gaucher disease, sialic acid
storage disease, sialidosis, aspartylglycosaminuria
Orotic acid
Indic.: Suspected heterozygous OTC deficiency, urea cycle defects, disorders of
pyrimidine metabolism, mitochondrial disorders, allopurinol test
Method: HPLC, tandem MS, capillary electrophoresis
Sample: 5 ml urine
Findings: Elevation indicates increased production of mitochondrial carbamyl phosphate
(urea cycle disorders, see page 61) or disorder of pyrimidine metabolism;
unexplained elevations also in other disorders, e.g. Rett syndrome, Lesch-
Nyhan syndrome, “benign orotic aciduria”
Peroxisomal studies
Very long-chain fatty acids (VLCFA), phytanic acid, pristanic acid
Indic.: Suspected peroxisomal disorder (see page 124)
Method: GC-MS
Sample: 1 ml plasma
Findings: Specific elevations of fatty acids that are metabolised in the peroxisomes
Plasmalogens
Indic.: Suspected peroxisomal disorder (see page 124)
Method: GC-MS
Sample: Erythrocytes (EDTA whole blood)
Findings: Reduced concentrations in rhizomelic chondrodysplasia punctata and
peroxisome biogenesis disorders
Porphyrins
Indic.: Suspected porphyria (see page 150); tyrosinaemia type I (see page 72)
Sample: Random urine sample (20 ml), faeces (approx. 5 ml), heparinised whole blood
(5–10 ml), store in a cool and dark place, ship without additives
Pterins
Indic.: Hyperphenylalaninaemia, BH4 test, suspected neurotransmitter defect
Method: HPLC
Sample: Urine (5 ml) serum or CSF (1 ml); keep in a dark place (dark urine collection
bag), centifuge blood immediately, freeze all samples immediately, ship on
dry ice.
Alternatively: 5 ml urine, add 6 M HCl up to pH 1.0–1.5, add 100 mg MnO2,
shake for 5 min (ambient temperature), centrifuge for 5 min (4 000 rpm), send
supernatant protected against light (aluminium foil) by express mail.
Findings: Specific elevations or reductions of neopterin or biopterin
Purines and Pyrimidines

Indic.: Suspected disorder of purine or pyrimidine metabolism (see page 139);
unexplained neurological disorder, nephrolithiasis, renal failure, gout,
anaemia, immune deficiency; life threatening side-effects of pyrimidine
antimetabolites, i.e. pharmacogenetic complications
Method: HPLC, GC-MS (dihydropyrimidines), tandem MS, capillary electrophoresis
Sample: 5 ml urine (preferably morning sample) or 24 h urine collection (keep in a
cool and dark place), ship frozen (particularly for the diagnosis of
adenylosuccinase deficiency), otherwise preserve with 2–3 drops of
chloroform/10ml (do not acidify); record medication; for further modalities
see page 140
Pyruvate
Indic.: Pyruvate should not usually be measured as values obtained may be spurious
and lactate is the more relevant and reliable test. Pyruvate is sometimes used
to determine the lactate/pyruvate ratio. Never measure pyruvate without
lactate.
Method: Photometric
Sample: Perchloric acid extraction
Normal: Blood: 50–100 µmol/l; CSF: 70–140 µmol/l;
Lactate/pyruvate ratio: < 20 (elevated in respiratory chain disorders, typically
normal in PDH deficiency)
Perchloric acid extraction (deproteinisation of blood)

Indic.: Measurement of pyruvate or acetoacetate
Sample: Mix whole blood immediately 1:1 with cold 10% (+ 1 mol/l) HClO4,
shake for 30 sec, keep cold for 5 min, centrifuge cold, freeze supernatant
Serotonin
Indic.: Suspected disorder of biogenic amine metabolism; carcinoid syndrome
Method: HPLC
Sample: 2 ml EDTA whole blood + 6 mg ascorbic acid, freeze immediately at –70°C,
ship on dry ice
Sterol biosynthesis intermediates

Indic.: Suspected disorder of cholesterol biosynthesis, e.g. Smith-Lemli-Opitz
syndrome (see page 127)
Method: GC-MS
Sample: 1 ml plasma
Trimethylamine (TMA)
Indic.: Malodour, suspected trimethylaminuria (see page 154)
Method: Headspace GC; NMR spectroscopy
Sample: Random urine sample, acidify with HCl, send by express mail or on dry ice.
Findings: ' Free TMA or & TMA-oxide (normal > 90% of total TMA)
Biopsies and enzyme studies
Obtain local protocols and discuss modalities with laboratory/pathology before the
samples are obtained.
Leukocytes
$ 5–10 ml heparinised whole blood, shipment at ambient temperature within 24 hrs
Skin biopsy (fibroblasts)

$ In culture medium (if not available: NaCl 0.9%) % fibroblasts (do not freeze!)
$ Formalin % histology
$ Consider samples in glutaraldehyde (electron microscopy)
Conjunctival biopsy
Liver biopsy
$ Consider samples in glutaraldehyde (electron microscopy)
$ Consider samples for biochemical evaluation and enzyme studies: Freeze immediately
in liquid nitrogen
Muscle biopsy (see also page 89)

$ Thin muscle fibre in 2% glutaraldehyde (electron microscopy)
$ Several pieces of muscle fibre frozen immediately in liquid nitrogen (for histology
1 cm length with recognisable fibre structure), store at –70°C, for enzyme
histochemistry and immunohistochemistry, biochemical evaluation, enzymes studies,
mutation analysis as indicated
$ Immediate isolation of mitochondria for investigations in native tissue
$ Small piece for formalin fixation and paraffin preparation (do not freeze) for light
microscopy
Molecular genetic investigations
Indications
$ Primary diagnosis or confirmation of diagnosis in disorders in which a biochemical
or enzymatic diagnosis is not possible, not reliable or requires invasive procedures
(e.g. organ-specific disease expression, disorders of structural, receptor or membrane
proteins) or in disorders with single common mutations;
$ To obtain information on the course of disease and prognosis in disorders with
established genotype-phenotype correlations;
$ Prenatal diagnosis and family studies in genetic counselling.
General guidelines
Identification of a known disease-causing mutation is the ultimate proof of diagnosis and
may be valuable for genetic counselling and prenatal diagnosis. However, in view of
high costs and limited sensitivity of DNA studies it is important to consider several
aspects before mutation studies are requested.
Are mutation studies necessary?

Enzyme studies or other functional (phenotypic) investigations, if available, are usually
more (cost-)effective for reaching a diagnosis. Mutation analyses, for example, are not
really essential to confirm the diagnosis of PKU although they may help in understanding
the patient’s phenotype. On the other hand, mutation analyses may be the diagnostic
method of choice when biochemical findings are inconsistent or unreliable, when
functional tests are tedious, unpleasant or potentially dangerous, or when the enzyme is
not expressed in a convenient tissue, such as in heterozygous OTC deficiency, hereditary
fructose intolerance, glycogen storage disease type I or HMG-CoA synthase deficiency.
How unlikely is the diagnosis when no mutation is found?

There is virtually no metabolic disorder in which all mutations are detected even with the
most sophisticated methods. Negative molecular results do not usually rule out a
diagnosis. DNA analysis reports in this situation should include information on the
sensitivity of the methodology. It is important to differentiate between mutation
scanning, mutation screening and direct sequencing.
$ Mutation scanning methods aim to detect both known and novel mutations in a gene.
Abnormalities found are confirmed by direct sequencing. Modern methods such as
dHPLC or denaturing gradient gel electrophoresis (DGGE) have a very high
sensitivity that may equal direct sequencing and are less expensive.
$ Mutation screening methods involve testing for a few known common mutations in a
gene. This approach is relatively inexpensive and may be indicated at an early stage,
e.g. in MCAD deficiency, LCHAD deficiency or hereditary fructose intolerance.
However, it is important to take the origin of the patient into consideration since the
frequency of mutations differs markedly between populations.
$ Direct sequencing is the gold standard of mutation detection. However, it does not
usually detect large deletions or genomic rearrangements. Quality control schemes for
DNA sequencing consistently show an error rate of at least 1% even in expert
laboratories. If the results do not fit the clinical picture it may be justified to check the
results in another laboratory.
$ Genomic quantification is necessary to identify large deletions or duplications that

occasionally cause single gene disorders. A novel molecular method (MLPA) has
been recently developed for this purpose and most likely will become widely used in
the future.
How likely is the diagnosis when mutations are found?

Novel DNA variants may be erroneously regarded as disease-causing when they are
silent and laboratory staff should be familiar with the full spectrum of mutations in the
genes studied. When two mutations are found in a recessive disorder, inheritance in trans
(on different chromosomes) should be confirmed. It is usually unwise to prematurely stop
the analyses – there may be additional (and more relevant) mutations in the gene. It is
often good to confirm mutations in parental samples, if available, but beware of non-
paternity.
How good are genotype-phenotype correlations?

Is the clinical picture fully explained by the genetic findings? Is the disorder fully
penetrant? Are there additional, non-genetic factors of pathogenesis?
Mutation analyses in children should only be performed if there is an important

medical consequence in childhood. Carrier analyses in healthy siblings of children with
metabolic disorders are not indicated and should not be carried out even when
requested by the parents. The results of mutation studies should be explained to the
patient (or his/her family) through full genetic counselling.
Sample
5–10 ml EDTA whole blood (or less), do not separate cells, shipment by ordinary mail
(within 24 hrs) or if frozen on dry ice (enquire with laboratory).
If no blood sample available: Filter paper card, biopsies, fibroblasts, etc.
Diagnosis of neurometabolic disorders
Indications (see page 144)

$ Neonatal progressive encephalopathy
$ Neonatal or infantile epilepsy that is refractory to treatment, infantile myoclonic
epilepsy
$ Extrapyramidal movement disorders, e.g. parkinsonism-dystonia, dyskinesia and
hypokinesia, progressive dystonia, chorea, hypotonia, ataxia, rigidity, muscular
hypertonia (extremities)
$ Ptosis, miosis, oculogyric crises
$ Disturbances of autonomic regulation, e.g. hypersalivation, disturbed intestinal
motility, disturbances of temperature regulation
First-line investigations in blood and urine

$ Whole blood count, clinical chemistry profile
$ Ammonia, lactate (repeated)
$ AA including homocysteine in plasma (centrifuge and freeze)
$ OA in urine (4-hydroxybutyrate, vanillyllactic acid, N-acetylaspartic acid)
$ Purines/pyrimidines in urine, sulphite test at the bedside
$ Prolactin in serum (secretion is dopamine-dependent)
$ Whole blood serotonin (altered in pterin defects, monoamine oxidase and aromatic L-
amino acid decarboxylase deficiencies)
Investigations in CSF
(A detailed guide for CSF investigations for neurometabolic disorders has been published
by Hoffmann et al. [1998] Neuropediatrics 29: 59–71)
$ Routine investigations including cytology, immunology, protein chemistry
– Glucose ratio CSF/plasma (< 0.35 in glucose transport defect)
$ Lactate; if elevated consider pyruvate
$ Amino acids (specific sensitive analysis required, concurrent CSF and plasma
samples)
– Glycine ratio CSF/plasma (normal < 0.04, neonate < 0.08; elevated in non-ketotic
hyperglycinaemia)
– Serine ratio CSF/plasma (< 0.2 in serine synthesis defects)
– Alanine and threonine (mitochondrial disorders)
$ Biogenic amines and metabolites in CSF
$ Pterins in CSF (special sample tube), possibly also in plasma and urine
$ 5-Methyltetrahydrofolate in CSF
Special investigations
$ Phenylalanine challenge (see page 50)
$ Serotonin in EDTA whole blood
$ Free GABA in CSF
$ Enzyme analyses (e.g. dihydropteridine reductase, aromatic L-amino acid
decarboxylase)
$ Mutation analyses
CSF – sample preparation and shipment

In contrast to inborn errors in catabolic pathways, neurotransmitter defects are reflected
by the interplay of biosynthesis, degradation and receptor status. Even borderline
abnormalities can be diagnostic and their recognition requires a strictly standardised
sampling protocol and adequate age-related reference values. The concentrations of
several metabolites change with the respective CSF fraction (rostro-caudal gradient). It is
therefore essential to exactly label the CSF samples (fractions) that are sent to the
laboratory. Freeze CSF sample immediately at the bedside (no additives – dry ice), store
at –70°C. If blood-stained: Centrifuge before freezing (inform laboratory).
Age < 1 yr: Collect 0.5 ml fractions, use fractions 2–5 for metabolic investigations.
Age > 1 yr: Collect 1 ml fractions, use fractions 3–6 for metabolic investigations.
Ship on dry ice.
Other investigations
$ Magnetic resonance spectroscopy of the brain allows the regional semi-quantification
of various metabolites including creatine, lactate and various neurotransmitters. It was
central to the discovery of the disorders of creatine metabolism.
$ NMR spectroscopy of CSF and other body fluids is a powerful method to identify
known and unknown key metabolites and has led to the identification of several novel
disorders, e.g. of polyol metabolism.
Function tests
Many metabolic disorders are best recognised through metabolic profiling, i.e. repeated
measurement of appropriate metabolites (glucose, lactate, amino acids, etc.) throughout
day (and night). This approach is also used to assess the response to external factors and
to monitor and tailor treatment. Sometimes controlled function tests are required to show
that a patient responds abnormally to specific metabolic challenge.
Metabolic Profiling
Indications
$ Evaluation of substrate metabolism (mitochondriopathies, disorders of glycogen
homoeostasis, disorders of fatty acid oxidation)
$ Evaluation of nitrogen disposal (urea cycle disorders)
$ Hypoglycaemia of unknown cause
$ Monitoring of treatment, e.g. assessment of glucose homoeostasis and catabolism in
disorders with reduced fasting tolerance
Procedure
$ Obtain a fasting urine sample and blood samples before breakfast in the morning:
– Glucose, lactate, alanine (amino acids)
– Consider acylcarnitines, free fatty acids, 3-hydroxybutyrate
– Consider ammonia
– Store serum sample for additional analyses
– Urine: Ketostix; consider organic acids and orotic acid
$ Obtain blood samples before and one hr after each meal throughout the day:
– Glucose, lactate, consider amino acids (Ala) and ammonia; store serum sample
$ Consider one blood sample during the night
– Glucose, lactate, amino acids (Ala); store serum sample.
Other parameters may be included depending on clinical features and suspected
disorders.
Interpretation
$ Hypoglycaemia < 2.6 µmol/l (< 45 mg/dl): See page 6
$ A possible mitochondrial disorder (see page 87) may be indicated by:
– Postprandial elevation of lactate (> 2.1 mmol/l) or rise > 20%
– Paradoxical postprandial ketosis
– Postprandial elevation of alanine > (600–700 µmol/l), alanine/lysine ratio > 3
$ Normalisation of elevated lactate in preprandial/fasting sample: Consider pyruvate
dehydrogenase deficiency
$ Preprandial hypoglycaemia with elevated lactate: Consider glycogen storage disease
type I
$ Postprandial elevation of ammonia, glutamine or orotic acid: Consider mild variant of
urea cylce disorder
Function tests 45
Glucose challenge
Glucose is catabolised to pyruvate which enters mitochondrial energy metabolism (see

page 87). Mitochondrial disorders occasionally show a significant elevation of lactate
only after substrate (glucose) challenge. Glucose challenge is contraindicated when
lactate has been consistently elevated or when a significant postprandial increase of
lactate has been demonstrated during metabolic profiling. In these cases, appropriate
enzyme studies (muscle biopsy) and possible molecular analyses should be undertaken
upon completion of the basic biochemical analyses.
Indications
$ Suspected mitochondrial disorder but apparently normal lactate values
$ Suspected glycogen synthase deficiency (hepatomegaly should be excluded)
$ Suspected glycogen storage disease, normal mutation/enzyme studies (patient should
have recurrent preprandial hypoglycaemia with elevated lactate, glucose should be
low normal at beginning of test)
Procedure
Before commencing test
$ Complete basic investigations including repeated lactate, organic acids, alanine
(amino acids), etc.
$ Glucose challenge should be carried out in the morning after overnight fasting
(younger infants: > 4–5 hrs after last meal)
At start of test
$ Secure i.v. access
$ Collect base-line blood samples, measure lactate, glucose, acid-base status
$ Give glucose 2 g/kg (max. 50 g) as special drink or 10% oral solution (store in fridge
– more palatable when chilled), consider nasogastric tube in small children (flush
with water)
$ Collect blood samples after 30, 60, 90, 120, 180 min: Measure lactate, glucose, acid-
base status
Collect urine for 2 hrs, analyse organic acids, lactate
Interpretation
Lactate should not rise > 20% and should not reach pathological values (> 2.1 mmol/l).
Acid-base status and urine analyses should remain normal. Glucose levels should rise and
remain within the normal range. A marked elevation of lactate may indicate a
mitochondrial disorder which, however, is not excluded by a normal result. An excessive
rise of glucose and lactate may indicate glycogen synthetase deficiency (GSD0). An
inappropriate increase of glucose and decrease of lactate may indicate Fanconi-Bickel
disease. A fall of lactate after glucose challenge may indicate glycogen storage disease
type I.
Fasting test
The response to fasting is altered in many inborn errors of metabolism including

hormonal disorders, disorders of gluconeogenesis, glycogenolysis and fatty acid
utilisation. Affected children may be asymptomatic and may show normal laboratory
results until they become ill or metabolically stressed. Assessment of metabolic changes
in response to fasting may be helpful in cases in which extensive investigations have
failed to lead to the diagnosis. Controlled fasting is also used to determine a safe fasting
tolerance to tailor therapy in individual patients, e.g. in patients with long-chain fatty acid
oxidation disorders. A fasting test is rarely indicated before the age of 6 mths.
Caution: In some patients fasting can lead to the production of toxic metabolites and
severe, sometimes fatal complications. It is essential to complete metabolic profiling
including acylcarnitine analysis (dried blood spots) and other metabolic investigations
including functional or molecular analyses prior to a fasting test. In general, fasting
tests for metabolic disorders should only be performed in specialist metabolic
units.
Indications
$ Hypoglycaemia of unknown cause
$ Assessment of fasting tolerance
Procedure
Before commencing test
$ Complete other metabolic investigations including metabolic profiling; obtain normal
results for carnitine status, organic acids, acylcarnitines and, where indicated, other
special investigations/tests. Fasting tests should be avoided for the diagnosis of fatty
acid oxidation disorders; as far as possible these should be excluded prior to fasting.
$ Stable metabolic state for > 3 mths; normal diet, good nutritional state
$ The maximum duration of the fast should be decided before starting and will be
determined from the history (expected fasting tolerance) and the age of the child.
Unless otherwise directed, this should be as follows:
Age < 6 mths 6–8 mths 8–12 mths 1–2 yrs 2–7 yrs > 7 yrs
Length 8 hrs 12 hrs 16 hrs 18 hrs 20 hrs 24 hrs
$ The fast should be timed so that there is negligible risk of clinical symptoms before
8:00 a.m. and blood specimens can be collected during the working day.
$ In special circumstances (e.g. suspected fructose-1,6-biphosphatase deficiency)
prepare glucagon test for the end of fasting.
$ Obtain informed consent from the parents (sequelae of hypoglycaemia, e.g. seizure).
$ Prepare an individual test form for recording clinical data and laboratory results.
At start of test
$ An indwelling cannula should be in place throughout the test, both to collect the
blood samples without difficulty and to give i.v. glucose if necessary. The test has to
be stopped if the line is lost.
Function tests 47
$ Carefully record the time when the fast started and when samples were taken. This is
essential for interpretation.
$ The child's clinical condition must be watched carefully. Document in the notes how
well the fast is tolerated and the clinical state at the end of the fast.
$ If the child is thirsty plain water may be given and this should be encouraged.
Samples
$ Start of fast:
– Bedside glucose
– Laboratory blood glucose, blood gases
– Store additional serum sample
– Urinary organic acids, ketostix
From the first missed feed onwards (usually 8:00 a.m.), laboratory blood glucose (or
bedside glucose) should be measured hourly so as to identify hypoglycaemia without
delay. All urine passed should be checked for ketones. Store serum samples for
possible additional investigations every time a venous blood samples is taken. Care-
fully label all samples immediately and freeze if necessary. Pyruvate and acetoacetate
are not routinely measured as these samples require deproteinisation at the bedside.
$ 8:00 a.m. blood tests:
– Bedside glucose
– Laboratory blood glucose, blood gases, lactate
– Consider free fatty acids, 3-hydroxybutyrate
$ End of fast blood tests:
– Bedside glucose
– Laboratory blood glucose, blood gases, lactate
– Free fatty acids, 3-hydroxybutyrate
– Insulin, cortisol, growth hormone
– Carnitine status, acylcarnitines
– Amino acids
$ Collect first urine sample after end of fast:
– Organic acids
– Ketostix
– Store part of the urine sample
In case of hypoglycaemia < 2.6 µmol/l (< 45 mg/dl) or clinical symptoms

(e.g. drowsiness)
$ Collect samples and terminate fast, ask laboratory for an urgent blood glucose result
on this sample; the end-of-fast specimens should still be collected if the child has a fit
although the lactate value may be falsely elevated
$ If the child is symptomatic: Give i.v. glucose 0.2 g/kg (2 ml/kg of 10% dextrose,
prepared beforehand) as a slow bolus
$ If the child is still symptomatic after the bolus: Check bedside glucose; only give
more glucose if glucose is low (< 3 mmol/l) as too much CAN BE HARMFUL!
Suitable infusion: 5–8 mg/kg/min (3–5 ml/kg/hr of 10% dextrose)
$ If the child is asymptomatic: Give a carbohydrate drink followed by something to eat
$ Before discharging a child after the test, a meal should be seen to have been eaten and
tolerated by the child
Interpretation
Hypoglycaemia below 2.6 mmol/l or symptoms of reduced consiousness are abnormal
until proven otherwise; for interpretation see also page 6. Blood concentrations of free
fatty acids (FFA) and subsequently 3-hydroxybutyrate rise during the test; high
concentrations of FFA but an insufficient increase in 3-hydroxybutyrate (see page 158
for normal values) indicate a disorder of fatty acid oxidation or ketogenesis. Blood
lactate concentrations should remain below 2 mmol/l but may be falsely elevated if the
child is struggling. Hypoglycaemia with elevated lactate and ketosis may be found in
glycogen storage or gluconeogenesis disorders and mitochondrial disorders. Elevated
alloisoleucine (plasma amino acids) is indicative of (intermittent) maple syrup urine
disease. Hyperinsulinism should be suspected if plasma insulin exceeds 2 IU/l at the time
of hypoglycaemia (see page 109), whilst plasma cortisol below 400 nmol/l may indicate
adrenocortical insufficiency.
Glucagon Test
The glucagon test examines the availability of glycogen for compensation of low blood
glucose. It has been largely superseded by enzyme or mutation studies but may be useful
in some circumstances.
Indications
$ Confirmation of a glycogen storage disorder
$ Confirmation of depleted glycogen stores at the end of a fasting test, indicative of
disorders of gluconeogenesis
$ Assessment of glycogen stores in neonatal hypoglycaemia and suspected congenital
hyperinsulinism
Test requirements
Low blood glucose < 3.5 mmol/l (< 60 mg/dl) at baseline; the patient should remain
fasting unless there are symptoms of hypoglycaemia or blood glucose decreases further.
Procedure
$ Base-line blood glucose
$ Give 500 µg (or 30–100 µg/kg) glucagon i.m.
$ Blood glucose after 15, 30, 45 and 60 min
$ Include analysis of blood lactate when a glycogen storage disease is a possibility.
Interpretation
Blood glucose should rise by more than 1.4 mmol/l (25 mg/dl) within 45 min. An
insufficient rise indicates depleted glycogen stores or inability to convert glycogen into
glucose. This may be observed in disorders of gluconeogenesis (e.g. fructose-1,6-
biphosphatase deficiency) at the end of a fasting test. Blood glucose remains low but
lactate increseases in glycogen storage diseases. There is a normal increase of blood
glucose in congenital hyperinsulinism.
Function tests 49
Tetrahydrobiopterin (BH4) test
BH4 is a cofactor of phenylalanine hydroxylase (PAH) and other hydroxylases (see also
page 146). Administration of BH4 in individuals with hyperphenylalaninaemia leads to a
reduction of plasma Phe concentrations when there is either a primary disorder of BH4
metabolism or a cofactor-sensitive form of phenylketonuria (PKU).
Indication
Diagnosis of BH4 cofactor deficiency in children with hyperphenylalaninaemia detected
by neonatal screening. The test may also identify BH4-sensitivity in children with PKU
(PAH deficiency), however, treatment of PKU with BH4 has not yet been fully evaluated
(2004) and cannot yet be recommended as a standard treatment option.
Test requirements
Plasma Phe should be greater than 400 µmol/l (6 mg/dl). Combination with single dose
Phe loading prior to BH4 administration is not recommended as the results are difficult to
interpret. In addition to the BH4 test, dihydropteridine reductase activity should be
determined in a filter paper-card (usually sent together with the BH4 test samples).
Procedure
$ Obtain baseline blood and urine samples
$ Give 20 mg/kg BH4 diluted in water 30 min before normal meal
$ Obtain blood samples after 1, 2, 4, 8 + 24 hrs, collect urine for 4–8 hrs (must be
protected from light)
Samples
1–2 ml EDTA/heparin blood for Phe/Tyr analysis: Separate and freeze plasma
immediately, ship on dry ice.
5 ml urine for pterin analysis: Protect against heat and light, freeze immediately and send
on dry ice, or oxidise urine with MnO2 and send by express mail (see page 37).
Interpretation
Phe values in classical PKU remain high after BH4 administration, whilst a marked
decrease in Phe and rise in Tyr indicate cofactor deficiency (i.e. a pterin defect, see page
146). A slow and moderate decrease in Phe indicates BH4-sensitive PKU.
Phenylalanine challenge
The Phe challenge test investigates the hydroxylation capacity of Phe to Tyr, thereby
examining the function of the enzyme phenylalanine hydroxylase as well as the
availability of the cofactor BH4. Relevant for interpretation are the respective readings of
Phe, Tyr and pterins after Phe challenge.
Indications
$ Undiagnosed dystonic movement disorder, suspected Segawa syndrome
$ Suspected disorder of biogenic amine or pterin metabolism (see page 144)
Procedure
The test should be carried out at least 1 hr after the last meal.
$ Obtain blood sample for baseline values
$ Give 100 mg/kg L-phenylalanine in orange juice, if necessary through nasogastric
tube
$ Obtain blood samples after 1, 2, 4 and 6 hrs
Samples
Approx. 2x1 ml EDTA/heparin blood at each time point, centrifuge and freeze plasma
immediately (two portions of 0.5 ml), ship on dry ice. Analyse Phe, Tyr, plasma pterins.
Interpretation
A slow decrease of Phe and a delayed increase of Tyr indicate reduced hydroxylation
capacity. If biopterin rises, a defect of pterin metabolism is excluded and the defect lies
in phenylalanine hydroxylase, e.g. heterozygosity for PKU.
Function tests 51
Allopurinol test
The allopurinol test detects increased throughput in pyrimidine synthesis (see page 142),
e.g. due to increased carbamylphosphate production from mitochondrial detoxification of
ammonia (see page 61).
Indication
Suspected heterozygous or mild ornithine transcarbamylase deficiency.
$ Unclear transient or intermittent hyperammonaemia with neurological symptoms (e.g.
epilepsy, ataxia)
$ Unclear comatose or encephalopathic episodes, neurodegenerative disorders in girls
$ Females at risk of OTC deficiency when mutation cannot be identified in propositus
Procedure
Avoid caffeine (decaffeinated coffee is acceptable), tea, cocoa, chocolate, cola, benzoate-
containing beverages 24 hrs before test. Women should be 7–12 days after their last
menstrual period if possible. The test is usually started in the morning.
$ Basal values: Collect urine sample
$ Give oral allopurinol: 100 mg (< 6 yrs), 200 mg (6–10 yrs), 300 mg (> 10 yrs)
$ Collect urine in 4 fractions: 0–6 hrs, 7–12 hrs, 13–18 hrs, 19–24 hrs
Samples
Obtain 10 ml of each urine fraction, freeze and send frozen, or conserve with 3 drops of
chloroform and send by express mail. Label sample tubes accurately, inform laboratory
of all medication taken on the preceding days. Quantification of orotic acid and orotidine
should be done by HPLC (rather than by a colorimetric method; see page 36).
Interpretation
Excessive increase of orotic acid and orotidine indicates increased throughput in
pyrimidine synthesis. The test has only a moderate sensitivity and specificity, and test
results may be false positive or false negative. A negative allopurinol test (or protein
challenge) does not exclude heterozygous OTC deficiency as mosaicism in the liver
(lyonisation) may be skewed in favour of normal hepatocytes to a degree that renders the
detection of metabolic effects impossible. If in doubt, consider mutation analysis or liver
biopsy (enzyme analysis).
Forearm ischaemia test
The ischaemia test investigates muscular energy production through anaerobic glycolysis
(lactate production) and activation of the purine nucleotide cycle (deamination of AMP
to IMP, with ammonia production). It is indicated in patients with exercise-induced
muscle pain (see page 16). However, this test is painful and requires very considerable
co-operation of the patient and therefore is difficult or impossible to perform in younger
children. The test results are invalid if there is an insufficient increase in both lactate
and ammonia.
Procedure
$ Organise dynamometer, sphygmomanometer or hand-powered torch.
$ Obtain urine sample 20–30 min before test, determine myoglobin;
subsequently 20–30 min bedrest
$ Insert large i.v. line into cubital vein of the test arm (right arm when right-handed),
obtain baseline blood sample (lactate, ammonia, CK).
$ Inflate a blood pressure cuff on upper arm to 20 mmHg > systolic blood pressure.
$ Instruct patient to squeeze dynamometer (to 80% max. strength) sphygmomanometer
(over 100 mmHg) or hand-powered torch with maximum effort every 1–2 sec for 2
min (strong continuous encouragement!), then release cuff.
$ Obtain blood samples from i.v. line 1, 3, 5 and 7 min after muscle activity, determine
lactate, ammonia, CK.
$ Obtain urine sample after muscle activity, determine myoglobin
Interpretation
$ Normal: Increase of lactate (> 2 mmol/l above baseline value) and ammonia
(> 50 µmol/l above baseline value)
$ Insufficient increase in both lactate and ammonia: Test invalid (insufficient muscle
activity)
$ Insufficient increase of lactate: % Deficient glyco(geno)lysis
$ Insufficient increase of ammonia: % Muscle-AMP-deaminase deficiency
$ Normal increase of lactate and ammonia but elevation of CK or myoglobin: % Long-
chain fatty acid oxidation defect
Neonatal screening 53
Neonatal screening
Neonatal population screening was introduced for the diagnosis of phenylketonuria in the
1960s and was later extended to a few other disorders. Recently, neonatal screening by
tandem MS has been introduced in several centres, allowing the diagnosis of many
additional disorders of intermediary metabolism.
Disorders detected by neonatal screening

$ Most programmes: Phenylketonuria, hypothyroidism
$ Regional variation: Galactosaemia, biotinidase deficiency, maple syrup urine disease,
adrenogenital syndrome, cystic fibrosis, sickle cell anaemia, thalassaemias.
$ Tandem-MS (some countries): Aminoacidopathies, organic acidurias, fatty acid
oxidation disorders, some urea cycle defects
What to do when galactose is elevated
Make sure that appropriate blood samples are obtained at the start of a lactose-free
diet. If in doubt: store filter paper card with dried blood spots + 2 ml EDTA whole
blood at room temperature. Diagnosis of classical galactosaemia by measuring GALT
activity should be pursued also after start of diet. Examine parental GALT activities if
the child has had an exchange transfusion.
Galactose (total) 20–30 mg/dl (1.1–1.7 mM)

$ Repeat screening test (dried blood spot): Galactose, GALT activity
$ No treatment, outpatient review
Galactose (total) 30–40 mg/dl (1.7–2.2 mM)
$ Repeat screening test (dried blood spot): Galactose, GALT activity
$ Commence lactose-free milk, outpatient review and final decision about diet when
results are available
Galactose (total) > 40 mg/dl (2.2 mM)
$ Immediate hospital admission, commence lactose-free milk immediately.
$ Clinical assessment: General condition, thorough investigation of liver and renal
function (coagulation, ultrasound, etc.)
$ Specific investigations (page 35): Galactose, galactose-1-phosphate, GALT activity
Indication for dietary treatment in galactosaemia (see page 102)

The most important laboratory value in classical galactosaemia is galactose-1-phosphate
in erythrocytes which may rise up to 100 mg/dl (~ 4 mM; normal < 0.3 mg/dl ~ 11 µM).
Values may fall rapidly in the first months of life particularly in children with mild
galactosaemia (decreasing galactokinase activity).
Galactose-1-phosphate 0.5–2 mg/dl (19–76 µM) % lactose reduction

> 2 mg/dl (> 76 µM) % lactose-free diet
What to do when phenylalanine is elevated
Neonatal hyperphenylalaninaemia may be caused by

$ Primary deficiency of phenylalanine hydroxylase (page 71)
$ Phenylalanine hydroxylase deficiency due to disorders of tetrahydrobiopterin (BH4)
cofactor metabolism (page 146)
$ Prematurity
$ Hepatic/renal failure, tyrosinaemia, galactosaemia
$ Drugs: Trimethoprim, chemotherapeutic agents (methotrexate)
$ Total parenteral nutrition
Specific investigations
$ Plasma amino acid analysis: Page 31
$ BH4 test: Page 49
$ Pterin analysis: Page 37
$ PAH gene mutation analysis: Sensitivity > 98%; identification of pathogenic muta-
tions in both gene copies confirms PAH deficiency and gives an indication on disease
severity, however, mutation analysis is expensive, not universally available and not
strictly necessary for the management of patients.
Neonatal screening: Quantitative analysis of Confirmation of

consistently elevated plasma amino acids hyperphenylalaninaemia
phenylalanine (Phe) > 180 µmol/l / 3 mg/dl
Exclude terhydrobiopterin cofactor deficiency:

• BH4 test (if Phe > 400 µmol/L)
• Pterins (urine)
• Dihydropteridin reductase activity (filter paper card)
• Consider PAH gene mutation analysis (not essential)
No response to BH4 Phe reduction > 30 % in BH4 test

normal pterin studies
(PAH gene mutations) Normal pterin studies Abnormal
(PAH gene mutations) pterin studies
Phe > 600 µmol/l Phe consistently Phe > 600 µmol/l BH4 cofactor deficiency
(> 10 mg/dl) < 600 µmol/l (> 10 mg/dl)
Assay CSF neurotransmitters
Phenylketonuria Mild hyperphenyl- “BH4-responsive” Treatment with:
(PKU) alaninaemia (MHP) PKU L-Dopa + carbidopa
5-OH-tryptophan
Diet treatment Normal diet Diet treatment
May be eligible for BH4
diet if necessary,
Regular Phe control
treatment in the future consider BH4
Note: The diagnosis of PKU in neonatal screening does not preclude breast-feeding.
Neonatal screening 55
Tandem mass spectroscopy (tandem MS)
Tandem MS for the identification of acylcarnitines, amino acids and various other
metabolites is now routinely used for neonatal screening in several countries. It enables
the diagnosis and treatment of a much larger number of metabolic disorders (aminoacido-
pathies, organic acidurias, fatty acid oxidation disorders and some urea cycle defects) in
all newborns. Whilst this is of obvious benefit in severe medium-chain acyl-CoA de-
ficiency and glutaric aciduria type I, it has also led to the identification of many children
with mild biochemical abnormalities or disease variants of doubtful clinical relevance. In
consequence, neonatal screening by tandem MS may lead to unnecessary treatment of
healthy children as well as undue anxiety of parents. Large multi-centre studies to assess
the benefits and problems of this method are under way in several countries.
Disorder Page Key metabolites Advice (asymptomatic patient)

Phenylketonuria 71 Phe, Tyr Urgent hospital admission
Maple syrup urine disease 73 Val, Leu(Ile) Immediate hospital admission
Citrullinaemia 63 Cit Immediate hospital admission
Argininosuccinic aciduria 63 Asa Immediate hospital admission
Propionic aciduria 65 C3, C3/C0, C3/C2, Immediate hospital admission
Methylmalonic acidurias 66 C4DC
Malonic aciduria 69 C3DC, C4DC Urgent hospital admission
Isovaleric aciduria 65 C5, C5/C2 Immediate hospital admission
2-Methylbutyric aciduria 67 (methyl-C4)
3-Methylcrotonylglycinuria 66 C5OH, C6DC Urgent metabolic consultation
Multiple carboxylase defic. 69 (C4OHDC) Urgent hospital admission if
values very high
3-Methylglutaconic aciduria I 66
HMG-CoA lyase deficiency 97
Glutaric aciduria I 67 C5DC (Glut) Urgent hospital admission
Beta-oxothiolase deficiency 98 C5:1 Urgent hospital admission
Carnitine transporter defic. 95 Very low C0 Urgent metabolic consultation
CPT-I deficiency 95 C0/(C16 + C18) Immediate hospital admission
Carnitine translocase defic. 95 C16, C18; low C0 Immediate hospital admission
CPT-II deficiency 95
VLCAD deficiency 96 C14:1, C14:2 Immediate hospital admission
LCHAD deficiency 96 C16OH, C18:1OH Immediate hospital admission
MCAD deficiency 96 C8, C8/C2, C8/C12 Urgent metabolic consultation
Multiple acyl-CoA-DH defic. 97 Multiple (C4–C18) Immediate hospital admission
“Key metabolites” are elevated unless stated otherwise.
“Urgent admission/consultation” = within 1–2 days. DC = dicarboxylic acid.
Note: With the exception of classical galactosaemia and some long-chain fatty acid
oxidation disorders it is not usually necessary to stop breast-feeding.
Other anomalies detected Advice Page

High Tyr and Met Exclude tyrosinaemia type I; assess liver function 72
High Met, normal Tyr Exclude homocystinuria, other disorders of Met 77
metabolism
High Gly Consider non-ketotic hyperglycinaemia 80
High Arg Consider argininaemia 63
C5OH in older children Consider biotinidase deficiency 69
Low C0 Secondary or primary carnitine deficiency 95
High C4 (iso-C4) Consider SCAD deficiency, isobutyric aciduria 96, 67
57
Metabolic pathways
and their disorders
Amino acid and protein metabolism

Deficiencies of enzymes involved in amino acid metabolism frequently result in
accumulation of toxic substances and subsequent organ damage. The brain, liver and
kidneys are the most frequently affected organs. Acute symptoms are often associated
with catabolic states that lead to the breakdown of endogenous proteins and the release of
large amounts of amino acids. The clinical features result from the toxicity of the
accumulating metabolites and concurrent product deficiency, the severity of the enzyme
deficiency, and the extent of protein intake or endogenous amino acid release in protein
catabolism. Some disorders cause chronic neurological damage without acute de-
compensation. Many disorders of this group are recognised by neonatal screening with
tandem MS (page 55). Most aminoacidopathies are caused by deficiencies of cytosolic
enzymes and are recognised by amino acid analysis in plasma (or urine). The classic
organic acidurias are caused by deficiencies of mitochondrial enzymes required for the
(beta-oxidative) breakdown of coenzyme A-(CoA-)activated small carbonic acids (after
deamination of amino acids) and are diagnosed by the analysis of urinary organic acids.
Organic acidurias frequently disturb energy metabolism and cause metabolic (lactic)
acidosis. Treatment usually involves (a) protein restriction, (b) supplementation of amino
acids with unimpaired metabolism as well as trace elements, and (c) specific measures
for detoxification if indicated. Treatment is not restricted to childhood but usually must
be continued throughout life.
Typical presenting features

$ Acute coma/ataxia/encephalopathy without evidence of encephalitis
$ Acute, unclear deterioration or prolonged disease course of a non-specific infection
$ Undiagnosed progressive neurological symptoms
$ Undiagnosed multi-systems disorder
$ Undiagnosed acidosis
$ Ketonuria in the neonate
$ Hypoglycaemia
$ Hyperammonaemia
Age of presentation
Disorders of amino acid metabolism can present at any age but are not usually sympto-
matic at birth or on the first day of life. Disorders with acute presentation often present at
times of protein catabolism, e.g. in the neonatal period (metabolic transition, delayed
food intake), late infancy (change to protein-rich meals with greater intervals; common
infections with fever, vomiting and reduced food intake) or puberty (changes in growth
rate, psychosocial factors).
58 Metabolic pathways and their disorders
Principles of treatment
This section explains general rules for treatment once the diagnosis is known. See page 3
for the management of children with metabolic decompensation of unknown cause and
page 8 for the emergency treatment of hyperammonaemia.
In disorders with acute presentation, increased protein breakdown while in a catabolic

state (fasting, infection, vaccination, surgery) may cause the accumulation of large
amounts of toxic metabolites in a very short time, leading to severe CNS damage or
death. In such disorders it is imperative to interrupt a catabolic state at an early stage of
impending decompensation. As this usually happens at home, it is essential to educate the
family about how to react adequately to the metabolic state.
Patients should carry an emergency card or bracelet containing essential information and
phone numbers as well as instructions on emergency measures. Vaccinations should be
carried out as recommended and should include vaccinations against varicella, hepatitis
A and influenza. Special precautions must be taken before and after operations.
Principles of long-term treatment

1. Diet: Protein restriction plus a semisynthetic amino acid supplement that does not
contain the amino acids whose breakdown is blocked; supplementation of minerals
and trace elements. Beware of protein deficiency due to “overtreatment” – may cause
protein catabolism (may be recognised by plasma amino acid analysis).
For minimal protein requirements see table on opposite page.
2. If indicated give specific detoxifying drugs, e.g. in urea cycle defects
3. If indicated give specific vitamins or cofactors, e.g. in biotinidase deficiency and
holocarboxylase synthetase deficiency, vitamin B6- or B12-dependent homocystein-
aemias, vitamin B12-dependent methylmalonic acidurias, vitamin B2-dependent
multiple acyl-CoA dehydrogenase deficiency
4. Give carnitine (50–100 mg/kg/day) in all disorders that cause intramitochondrial
accumulation of CoA esters, i.e. most organic acidurias
5. Monitor growth regularly: Weight, size, head circumference, development
6. Regular laboratory monitoring of patients on protein-restricted diets (metabolic
parameters depend on the disease): Blood count, calcium, phosphate, magnesium,
iron, liver and kidney function tests, alkaline phosphatase, total protein, albumin, pre-
albumin, cholesterol, triglycerides, vitamins, carnitine, acid-base status, ammonia,
lactate, amino acids in plasma, organic acids in urine, acylcarnitines
Amino acid and protein metabolism 59
Protein requirements (g/kg/day)

Age Revised safe values German Society for
(Dewey et al. 1996) Nutrition 1985
0–3 mths 2.7–1.6 2.7–2.1
4–12 mths 1.4–1.1 2.1–2.0
1–3 yrs 1.0 1.7
4–6 yrs 0.9 1.6
7–9 yrs 0.9 1.4
10–12 yrs 0.9 1.1
13–15 yrs 0.9 1.0
Adults 0.8 0.9
Revised safe values from Dewey et al. (1996) Eur J Clin Nutr 50 Suppl. 1: 119–147 are based
on an intake of high value protein and are used, e.g. for children with urea cycle disorders.
Protein requirements may be higher in the treatment of PKU or other disorders where the intake
of single amino acids is restricted; in these children it may be more appropriate to provide more
natural protein as in the recommendations of the German Society for Nutrition (1985).
Treatment of intercurrent illness at home

In order to prevent metabolic decompensation during intercurrent illness with poor
feeding, vomiting, fever, etc.:
$ Stop protein intake, give sufficient fluid (water, tea) and calories (carbohydrates as
glucose polymers/maltodextrin) with some salt according to the following table:
Age Glucose polymer/maltodextrin solution
% Kcal/100 ml Daily amount
0–1 yrs 10 40 150–200 ml/kg
1–2 yrs 15 60 95 ml/kg
2–10 yrs 20 80 1 200–2 000 ml/day
> 10 yrs 25 100 2 000 ml/day
$ Start adding protein after 24–48 hrs at the latest: One day half the normal amount of
protein, one day ¾, then the full amount of normal protein.
$ Assess nutritional state one week after the illness (plasma amino acids) – there may
be a transient increase in protein requirement after an intercurrent illness.
Immediate hospital admission and i.v. treatment is indicated when vomiting persists,
fluid and dextrose intake remain poor, the clinical condition deteriorates or the disease
course is prolonged. When presenting in an emergency clinic these patients must be
assessed by a specialist immediately and further tretment initiated without delay.
Emergency treatment in the hospital

Every person with a known disorder of amino acid metabolism and the possibility of
acute decompensation should be attached to a hospital with a dedicated team of
metabolic specialists that can be reached at any time. For holidays it is prudent to enquire
about metabolic services in the respective region.
1. Take appropriate blood samples: Basic laboratory tests (page 1), amino acids in
plasma, liver and renal function tests, etc.
2. Interrupt a catabolic state by high-dose energy substitution: 10% glucose infusion,

150 ml/kg/day (~10 mg/kg/min, ~60 kcal/kg/day) (exceptionally via nasogastric
tube), add i.v. insulin if necessary (check lactate); add parenteral lipids 1g/kg/day
3. Stop protein intake: The accumulation of toxic metabolites in some organic acidurias
can be reduced by intestinal antibiotics (metronidazole, colistine)
4. Ensure adequate fluid and electrolyte intake: Aim for a sodium concentration $140
mmol/l to reduce the risk of cerebral oedema
5. Start antibiotics if there is any suggestion of an infectious cause
6. Carry out detoxifying measures depending on the disease and laboratory findings:
Increased diuresis, dialysis, haemofiltration
7. Consider specific drug treatment (vitamins, carnitine, carbamylglutamate etc.)

depending on the disease and laboratory findings
Disorders of ammonia detoxification – urea cycle defects
Urea cycle defects are among the most common inborn errors of metabolism (cumulative
incidence approx. 1:8 000). They can present at all ages, are usually easy to diagnose (but
frequently overlooked) and in principle treatable. The emergency analysis of blood
ammonia must be part of the basic investigations in all patients with unclear
encephalopathy at at any age.
Biochemistry
NAGS
N-acetylglutamate Glutamate
! Orotic acid
Ammonia CPS1 Carbamyl-
phosphate Orotidine
HCO3- Uracil
Citrulline
OTC Aspartate
Mitochondrion
T ASS
Cytosol
Urea
Ornithine Cycle Argininosuccinate
Urea ASL
Arginase
Arginine
T = Ornithine transporter Fumarate
Ammonia (NH3) arising from amino acid metabolism is detoxified mainly through its
conversion to urea in the liver. The enzyme catalysing the inital condensation of
ammonia and bicarbonate, carbamylphosphate synthase I (CPS1), requires activation
by N-acetylglutamate which itself is formed by N-acetylglutamate synthase (NAGS).
Carbamylphosphate is subsequently bound to ornithine by ornithine transcarbamylase
(OTC) as a carrier molecule. Citrulline is formed, transported out of the mitochondrion
and bound to aspartate by argininosuccinate synthase (ASS). The resulting arginino-
succinate is split by argininosuccinate lyase (ASL) into fumarate and arginine which in
turn is hydrolysed by arginase into ornithine and urea. Urea, as a harmless carrier of
two N-residues, is excreted in the urine; ornithine is transported back into the
mitochondrion by the ornithine transporter, thus completing the urea cycle.
Hepatic NH3 detoxification is additionally effected (in low capacity) through the action
of glutamine synthase at the perivenous part of the hepatic lobule. The enzyme adds an
amino group to glutamate and thus gives glutamine a buffer function. An increased
glutamine concentration in plasma (normal < 700 µmol/l) is the most sensitive
indicator of insufficient urea synthesis. A liver bypass (e.g. open ductus venosus in the
neonate) causes hyperammonaemia with insufficient formation of both urea and
glutamine. Insufficient arginine intake (e.g. parenteral nutrition) or transport defects
involving the dibasic amino acids cause a deficiency of intramitochondrial ornithine,
accumulation of carbamyl phosphate and hyperammonaemia.
Clinical features
$ Neonates: Rapidly progressive symptoms appear in the first days of life after a short
symptom-free interval: Lethargy, poor feeding, hyperventilation, seizures, progressive
encephalopathy with deepening coma, temperature instability, loss of reflexes,
intracranial haemorrhages due to coagulation defect (check by ultrasound)
$ Infants and children: Failure to thrive, feeding problems, vomiting, chronic
neurological symptoms, episodic encephalopathy with lethargy, ataxia, seizures
$ Adolescents and adults: Chronic neurological or psychiatric symptoms, behavioural
problems, episodes of disorientation, lethargy, psychosis, recurrent encephalopathy
usually associated with high protein intake, catabolism or stress
Acute management
See page 8. The most urgent laboratory parameter is blood ammonia. Hyperammonaemia
is one of the most urgent emergencies in metabolic medicine and must be treated
immediately and aggressively.
Long-term treatment
1. Maintain anabolic state
2. Limit protein intake: If possible provide minimal requirements (see page 59) as
normal protein; if necessary replace natural protein (contains approx. 50% essential
amino acids) by half the amount of an essential AA mixture
3. Give arginine 100–200 mg/kg/day (OTC/CPS deficiency) or up to 600 mg/kg/day
(ASS/ASL deficiency). Citrulline (same dose) is an alternative in severe OTC/CPS
deficiency (eliminates an additional ammonium group but is more expensive than Arg
and only available as an oral formulation).
4. Remove ammonia: Na-benzoate 250–400 mg/kg/day oral (elimination of 1 mol NH3
per mol of glycine) and/or Na-phenylbutyrate 250–500 mg/kg/day oral (elimination of
2 mol NH3 per mol of glutamine)
5. Give vitamins and trace elements (e.g. folic acid 500 µg/day)
6. If carnitine is low: Carnitine 30–50 mg/kg
7. Consider lactulose 3 x 4–20 g/day (binds intestinal ammonia due to acid pH)
Monitor laboratory values frequently (initially daily) and adjust diet to avoid excessive
protein reduction (overtreatment). Target values:
$ NH3 < 80 µmol/l
$ Orotic acid < 10 mmol/mol creatinine (defects beyond CPS)
$ Gln < 800(–1 000) µmol/l (should not be too low during Na-phenylbutyrate therapy)
$ Gly 100–150 µmol/l (during Na-benzoate therapy)
$ Arg 80–150 µmol/l (if too low increase the dose of arginine/citrulline)
$ Essential AA should all be in the normal range, particularly during Na-phenylbutyrate
therapy. Specific target values: Ile > 25 µmol/l (marker of sufficient protein intake),
Thr > 100 µmol/l (> 70 in the 1st yr; marker of long-term exogenous protein intake,
may be elevated in plasma after a period of protein deficiency)
$ Avoid hypokalaemia during Na-phenylbutyrate or Na-benzoate therapy (check
regularly)
Sufficient fluid intake (> 1 000 ml/day)

Vaccinations as recommended, plus vaccinations against varicella, hepatitis A, influenca
Treat infections early, if necessary “blindly” with antibiotics
Avoid hidden nitrogen, e.g. liquorice (salmiac)
Ornithine transcarbamylase (OTC) deficiency

Clinical: Boys: Usually severe hyperammonaemia (lethal in the neonate); milder
variants not uncommon
Girls and women: Clinical picture variable even within a family, dependent on
the X-inactivation pattern in the liver
Genetics X-chromosomal semidominant (females may be symptomatic)
Incidence: 1:14 000 (most common urea cycle defect)
Diagn.: AA (plasma): ' Gln, & Cit, Arg (' Lys due to shortage of 2-oxoglutarate);
'' orotic acid/uracil (urine), mutation analysis, allopurinol test if appropriate
(see page 51), enzyme studies (liver)
Carbamylphosphate synthase I (CPS1) deficiency

Clinical: Often severe neonatal disease; milder variants occur at any age
Diagn.: AA (plasma): ' Gln, &-n Cit, Arg; normal or low orotic acid (urine); enzyme
studies (liver), mutation analysis
Citrullinaemia
Clinical: Often milder course with manifestation after the neonatal period
Enzyme: Argininosuccinate synthase (ASS)
Diagn.: AA (plasma): '' Cit, & Arg; ' orotic acid (urine); enzyme studies (fibroblasts)
Argininosuccinic aciduria
Clinical: Neurological and hepatic problems despite good control of NH3 levels with
sufficient arginine intake (detoxification of one molecule of NH3 via
argininosuccinic acid)
Enzyme: Argininosuccinate lyase (ASL)
Diagn.: AA (urine): '' argininosuccinic acid; AA (plasma): ' Cit, & Arg;
' orotic acid (urine); enzyme studies (erythrocytes, fibroblasts)
Argininaemia
Clinical: Relatively mild hyperammonaemia, rarely acute manifestation, progressive
spasticity (equinus position of the feet), seizures and mental retardation after
the 2nd yr due to high arginine levels
Enzyme: Arginase
Diagn.: AA (plasma): '' Arg (note: May be normal in the neonate);
'' orotic acid (urine); enzyme studies (erythrocytes)
Therapy: Na-phenylbutyrate, Arg-restricted diet
HHH syndrome (hyperammonaemia, hyperornithinaemia, homocitrullinuria)

Clinical: Variable encephalopathy; clotting disorder with reduction of factors VII and X
Bioch.: Disorder of ornithine transport between cytoplasm and mitochondrion
Diagn.: AA (plasma): '' Orn (breakdown requires mitochondrial OAT, see page 81;
normal values may be found in the neonate), n Arg, Cit; AA (urine): ' Orn, '
homocitrulline; enzyme studies (fibroblasts)
Therapy: Consider Orn supplementation (increases mitochondrial availability)
Other genetic defects of ammonia detoxification

$ N-Acetylglutamate synthase:deficiency – rare; usually severe disease (similar to CPS
deficiency); efficent treatment with supplementation of carbamylglutamate (100–300
mg/kg/day).
$ Citrullinaemia type II – Citrin deficiency. Treatment: Galactose-free diet, Na-
benzoate, Na-phenylbutyrate, arginine.
$ Lysinuric protein intolerance – deficient transport of dibasic AA (see page 82).
$ Hyperinsulinism-hyperammonaemia syndrome (see page 110).
$ Hypoprolinaemia (see page 81; paradoxical fasting hyperammonaemia).
Biochemistry: Metabolism of branched-chain amino acids
Valine Isoleucine Leucine

Aminotransferase Aminotransferase Aminotransferase
2-Oxo- 2-OH- 2-Oxo- Alloisoleucine 2-Oxo- 2-Oxoisocaproate

isovalerate isovalerate 3-methylvalerate isocaproate 2-OH-isocaproate
BCKDH BCKDH BCKDH
Isobutyryl-CoA 2-Methylbutyryl-CoA Isovaleryl-CoA 3-OH-isovalerate

IBD MBD IVD
Isovalerylglycine
Tiglyl-
Methylacrylyl-CoA Tiglyl-CoA 3-Methyl- 3-OH-isovalerate
glycine
crotonyl-CoA 3-Methylcrotonyl-
Hydratase Hydratase
MCC glycine
3-OH-isobutyryl-CoA 2-Methyl-
3-OH-butyryl-CoA 3-Methyl- 3-Methylglutarate
Deacylase
glutaconyl-CoA
MHBD
3-OH-isobutyrate Hydratase
2-Methyl-
DH 3-OH-3-methyl-
acetoacetyl-CoA
3-Oxothiolase
glutaryl-CoA
Methylmalonate
HMG-CoA lyase
semialdehyde DH
Propionyl-CoA Acetyl-CoA Acetoacetate

Carboxylase
3-OH-propionate
Methylmalonyl-CoA
Methylcitrate Krebs
Mutase
cycle
Succinyl-CoA
Branched-chain amino acids are metabolised predominantly in muscle and kidney. To-
gether with succinyl-CoA they are important substrates of gluconeogenesis. Disorders
affecting this pathway include maple syrup urine disease and the classical organic
acidurias as well as various disorders of vitamin metabolism (cobalamin, biotin). Most
disorders are diagnosed by the elevation of specific metabolites (e.g. methylcitric acid,
3-OH-isovaleric acid, methylmalonic acid) in urinary organic acid analysis.
Enzyme abbreviations: see description of individual disorders. DH = dehydrogenase.
Classical organic acidurias
Organic acidurias are disorders of intermediary metabolism with characteristic accumula-

tion of carboxylic acids identified by GC/MS analysis of urine. Most patients present
with systemic illness (classical organic acidurias) but it is now recognised that some have
only cerebral abnormalities. The most important organic acidurias are caused by
disorders involving the complex metabolism of branched-chain amino acids. The
mitochondrial accumulation of CoA metabolites is an important difference between
many organic acidurias and aminoacidopathies.
Clinical: 1. Neonatal form: Metabolic encephalopathy “intoxication type”: Lethargy,

feeding problems, dehydration, truncal hypotonia/limb hypertonia, myoclonic
jerks, neurovegetative dysregulation % cerebral oedema, coma, multi-organ
failure; unusual odour
2. Chronic intermittent form (manifestation up to adulthood): Recurrent
episodes of ketoacidotic coma, lethargy and ataxia, focal neurological signs,
stupor % coma, Reye syndrome
3. Chronic progressive form: Failure to thrive, chronic vomiting, anorexia,
osteoporosis, hypotonia, psychomotor retardation, recurrent infections
(particularly candida)
Lab.: Ketosis/ketoacidosis, ')lactate, ')NH3, hypoglycaemia (or hyperglycaemia),
neutropenia, thrombopenia, pancytopenia, & calcium
Diagn.: OA (urine): Specific metabolites; carnitine status; acylcarnitines; enzyme
studies; AA (plasma)
Therapy: (see page 60) Acute: Interrupt catabolic state with high-dose glucose infusion,
counteract acidosis, stop protein intake, remove toxins, give carnitine, etc.
Long-term: Diet – protein restriction; supplementation of unaffected amino
acids (carefully check Ile, should be > 25 µmol/l), minerals, vitamins, trace
elements; carnitine
Compl.s: Demyelinisation, brain necrosis (basal ganglia), nephritis, pancreatitis,
dermatoses % epidermolysis, osteoporosis, cardiomyopathy
Propionic aciduria (PA)

Enzyme: Propionyl-CoA carboxylase (PCC)
Bioch.: Biotin-dependent enzyme (but no biotin-responsive patient reported);
propionyl-CoA inhibits enzymes of the tricarboxylic acid cycle, the urea cycle
and other pathways
Diagn.: OA (urine): ')3-OH-propionic and methylcitric acids, ' C5 and C6 ketones;
&)carnitine; acylcarnitines: ')propionylcarnitine; AA (plasma): ')Gly, Ala
DD: Disorders of biotin metabolism
Therapy: Diet (& Ile, Val, Met, Thr; corresponding to valine tolerance);
L-carnitine (50–)100 mg/kg/day; consider metronidazole (10 mg/kg) and/or
colistin for 10 days/mth (& enteral propionic acid)
Compl.s: Mental retardation, extrapyramidal movement disorder, osteoporosis,
pancreatitis, cardiomyopathy
Methylmalonic aciduria (MMA)

Enzyme: Methylmalonyl-CoA mutase (MCM)
Bioch.: Vitamin B12-dependent enzyme (see page 75)
Diagn.: OA (urine): ')methylmalonic, 3-OH-propionic and methylcitric acids;
& carnitine; acylcarnitines; AA (plasma): ')Gly, Ala
DD: Disorders of vitamin B12-(cobalamin) metabolism, vitamin B12 deficiency
Therapy: Consider vitamin B12; otherwise like propionic aciduria
Compl.s: Mental retardation, extrapyramidal movement disorders; osteoporosis;
progressive renal failure (note: Creatinine is unreliable for the assessment of
renal function [low protein diet, reduced muscle mass] – determine GFR)
Isovaleric aciduria (IVA)

Enzyme: Isovaleryl-CoA dehydrogenase (IVD)
Bioch.: FAD-dependent enzyme (% electron-transfer flavoprotein, see page 93)
Diagn.: OA (urine): '')isovalerylglycine, 3-OH-isovaleric acid; & carnitine;
acylcarnitines: ')isovalerylcarnitine
Therapy: L-Carnitine (50–)100 mg/kg/day ± L-glycine 150–250 mg/kg/day;
diet (& Leu-restricted or low protein)
Progn.: Good if diagnosis is not delayed and strict therapy is maintained
3-Methylglutaconic acidurias (MGAs)

Heterogeneous group of disorders characterised by excretion of 3-methylglutaconic acid.
The genetic and biochemical basis is poorly understood for most disorders in this group,
which probably includes defects in mitochondrial energy metabolism (see page 87) as
well as in sterol synthesis (see page 127). Treatment is largely symptomatic.
Type IV: Unclassified (largest group): Dysmorphic features; variable, mostly cerebral
disease features
Type I: 3-Methylglutaconyl-CoA hydratase deficiency: Uncertain clinical relevance,
may be asymptomatic
Type II: Barth syndrome: X-linked (cardio)myopathy, growth retardation, neutropenia;
deficiency of tafazzin (mitochondrial membrane protein) affecting phospho-
lipid metabolism
Type III: Costeff syndrome: Optic atrophy, extrapyramidal signs, spasticity; deficiency
of a mitochondrial membrane protein
3-Methylcrotonylglycinuria
Clinical: Common, mostly benign condition
Enzyme: 3-Methylcrotonyl-CoA carboxylase (MCC)
Bioch.: Biotin-dependent enzyme
Diagn.: OA (urine): ')3-OH-isovaleric acid, 3-methylcrotonylglycine; & carnitine
DD: Disorders of biotin metabolism
Therapy: Not usually necessary; consider diet (low protein), L-carnitine, L-glycine
Other organic acidurias

$ Multiple acyl-CoA dehydrogenase deficiency (FAD-dependent enzymes): See page 97
$ Multiple carboxylase deficiency (biotin-dependent enzymes): See page 69
$ HMG-CoA lyase deficiency: See page 97
$ 3-Oxothiolase deficiency: See page 98
Organic acidurias of doubtful clinical relevance

$ Isobutyric aciduria (isobutyryl-CoA dehydrogenase [IBD] deficiency, valine
metabolism)
$ 2-Methylbutyric aciduria (2-methylbutyryl-CoA dehydrogenase [MBD] deficiency,
isoleucine metabolism)
$ 3-Hydroxyisobutyric aciduria (methylmalonate semialdehyde dehydrogenase or 3-
hydroxyisobutyrate dehydrogenase deficiency, valine metabolism); 3 patients with
repeated ketoacidosis, 2 brothers with dysmorphic facies and cerebral anomalies
“Cerebral” organic acidurias
Several organic acidurias present with (progressive) cerebral symptoms without basic
laboratory abnormalities such as hypoglycaemia or metabolic/lactic acidosis. The
diagnosis is made through the analysis of urinary organic acids, however, the specific
metabolites are sometimes only slightly elevated and may be overlooked.
Clinical features
Progressive ataxia, extrapyramidal signs, acute metabolic/epileptic encephalopathy,
myoclonic jerks, macrocephaly, sometimes non-specific psychomotor retardation.
Neuroradiological findings include progressive demyelinisation (particularly spongiform

encephalopathy), circumscribed brain atrophy, abnormalities in the basal ganglia,
cerebellar hypoplasia/aplasia as well as symmetric and/or fluctuating abnormalities in the
thalamus, hypothalamus, medulla and brain stem (DD: Leigh syndrome).
Glutaric aciduria type I (GA1)

Clinical: Macrocephaly, fronto-temporal atrophy; acute encephalopathic crisis (usually
age 6–18 mths) with destruction of the striatum, subsequently severe dystonic-
dyskinetic movement disorder; leucencephalopathy in adulthood
Enzyme: Glutaryl-CoA dehydrogenase (GCDH) in Lys/Trp metabolism, see page 74
Diagn.: OA (urine): ')Glutaric acid, 3-OH-glutaric acid (diagnostic); & carnitine;
acylcarnitines: ')Glutarylcarnitine; enzyme studies; mutation analysis;
note: Metabolic abnormalities may be fluctuating and inconsistent
DD: Mitochondrial disorders, multiple acyl-CoA dehydrogenase deficiency
(= glutaric aciduria type II)
Therapy: Strict adherence to emergency protocol in infancy and early childhood.
Carnitine 100 mg/kg/day, diet (Lys- and Trp-restricted, beware of Trp
deficiency!)
2-Methyl-3-hydroxybutyryl-CoA dehydrogenase (MHBD) deficiency

Clinical: Progressive “neurodegeneration”, loss of skills, choreoathetosis, epilepsy,
blindness; mild acidosis in catabolic states, cardiomyopathy
Genetics: X-chromosomal semidominant (females may be symptomatic)
Diagn.: OA (urine): ' 2-Methyl-3-hydroxybutyrate, tiglylglycine, normal 2-
methylacetoacetate; acylcarnitines usually normal; enzyme studies, DNA
analysis
Canavan disease
Clinical: Progressive psychomotor retardation, progressive epileptic encephalopathy,
macrocephaly, leukodystrophy (particularly subcortical U-fibres), optic
atrophy
Enzyme: Aspartoacylase
Diagn.: OA (urine): ')N-acetylaspartic acid; acylcarnitines normal; enzyme studies,
mutation studies
Therapy: Symptomatic
L-2-Hydroxyglutaric aciduria
Clinical: Progressive ataxia and mental retardation, epilepsy, peripheral leukodystrophy
(U-fibres), symmetric high signal (T2w) of dentate nucleus and pallidum
Diagn.: OA (urine, CSF): ' L-2-hydroxyglutaric acid, AA (CSF): ' lysine
Therapy: Satisfactory control of seizures with antiepileptic medication (control of
‘minor’ fits can be difficult)
Ethylmalonic encephalopathy
Clinical: Neurodevelopmental regression, pyramidal and extrapyramidal tract signs,
seizures, petechiae, orthostatic acrocyanosis, chronic diarrhoea; CNS
malformations; multiple lesions on MRI; lethal in infancy or early childhood
Genetics: Autosomal recessive, ETHE1 gene
Protein: Mitochondrial matrix protein of unknown function
Diagn.: Lactic acidaemia; acylcarnitines: ' C4, C5; OA (urine): ')Ethylmalonic acid,
methylsuccinic acid, C4–C6 acylglycines; COX deficiency in muscle
DD: See below
Differential diagnosis of ethylmalonic aciduria

Ethylmalonic acid can be derived from either the carboxylation of butyryl-CoA in fatty
acid oxidation or from the R-pathway of isoleucine metabolism.
Disease Additional features Page
SCAD deficiency Failure to thrive, hypotonia, metabolic acidosis, 96
retardation; mild SCAD variants of doubtful
clinical significance;)')butyrylcarnitine, -glycine.
Multiple acyl-CoA Metabolic acidosis, hypoglycaemia, hypotonia, 97
dehydrogenase deficiency dysmorphic features, malodour; various other
organic acids (glutaric, adipic, lactic acids etc.)
Ethylmalonic encephalopathy See above
Jamaican vomiting sickness Hypoglycin poisoning (ingestion of unripe ackee
fruit)
Other cerebral organic acidurias

$ 4-Hydroxybutyric aciduria (succinic semialdehyde dehydrogenase deficiency): See
page 147
$ D-2-hydroxyglutaric aciduria (enzyme unknown) – epileptic encephalopathy,
variable clinical features (vomiting, cardiomyopathy)
$ Malonic aciduria (malonyl-CoA decarboxylase deficiency) – relatively mild clinical
features; developmental retardation, epilepsy, recurrent vomiting. Therapy: Carnitine
supplementation, low-fat high-carbohydrate diet (experimental)
$ See also: Mitochondrial disorders, page 87
Disorders of biotin metabolism
Biochemistry Apocarboxylases
(PCC, MCC, PC, ACC)
Holocarboxylase
Protein bound Biotinidase
biotin (diet) Biotin synthetase
Holocarboxylases
Lysine Biotinidase
Proteolysis
Lysylpeptides
Biocytin,
short biotinylpeptides
The carboxylation of 3-methylcrotonyl-CoA, propionyl-CoA, acetyl-CoA and pyruvate

is biotin-dependent. Multiple carboxylase deficiency may be caused by deficient
activation of the apoenzymes (holocarboxylase synthetase [HCS] deficiency), deficient
release of biotin from biocytin of protein-bound biotin (biotinidase deficiency) or by
acquired biotin deficiency.
Multiple carboxylase deficiency (biotinidase, holocarboxylase synthetase)

Biotinidase deficiency is well treatable and measurement of the enzyme is included in the
neonatal screening programmes in some centres (enquire!). Holocarboxylase synthetase
deficiency is only covered by tandem mass spectroscopy neonatal screening.
Clinical: Metabolic acidosis, neurological symptoms, hypotonia, seizures, psychomotor
retardation, skin rashes, hair loss, immune defects
Manif.: HCS deficiency: Usually in the neonate
Biotinidase deficiency: Usually in infants or toddlers, often insidious
Diagn.: ')Lactate, ')NH3; AA (plasma): ')Ala;)& carnitine; OA (urine; CSF in rare
cases): ' lactate, 3-OH-isovaleric acid, methylcrotonylglycine, methylcitric
acid, etc.; enzyme studies: biotinidase (dried blood spot on filter paper card,
plasma), carboxylases (fibroblasts, lymphocytes). Metabolic abnormalities
may be fluctuating and inconsistent in biotinidase deficiency.
DD: Defects of single carboxylases; secondary biotin deficiency in valproate
therapy or as a result of gut sterilisation or the ingestion of massive amounts
of raw egg-white.
Therapy: Biotinidase deficiency: Biotin 5–10 mg/day;
HCS deficiency: Biotin 10–20(–40) mg/day
Disorders of the metabolism of branched-chain amino acids
Biochemie: Siehe Seite 64.
Maple syrup urine disease (MSUD)

The clinical picture of maple syrup urine disease, as in other aminoacidopathies, is
caused by the specific action of toxic metabolites (particularly 2-oxoisocaproic acid). In
contrast to the classical organic acidurias there is no accumulation of CoA metabolites
(no characteristic acylcarnitines) and acidosis or hyperammonaemia are not major
features of the disease.
Clinical: Severe form: Progressive encephalopathy from the 3rd–5th days of life:
Lethargy, feeding problems, somnolence, cerebral oedema, coma
Mild form: Psychomotor retardation, fluctuating/progressive neurological
disease, recurrent ketoacidotic decompensation (DD: Ketonaemic vomiting).
Urine odour may be highly characteristic (maple syrup-like)
Enzyme: Branched-chain !-oxoacid dehydrogenase (BCKDH) complex
= multi-enzyme complex similar to pyruvate dehydrogenase (PDH) complex
Genetics: Recessive inheritance, several proteins (E1", E1#, E2, E3)
E3 deficiency: Combined deficiency of several mitochondrial dehydrogenases
(see PDH deficiency, page 91)
Incidence: In Europe approx. 1:200 000
Diagn.: AA (plasma): ' Val, '' Leu, Ile, alloisoleucine (diagnostic);
OA (urine): ' branched-chain oxo- and hydroxyacids, e.g. 2-OH-isovaleric
acid, 2-oxoisocaproic acid
Therapy: Acute: Glucose + insulin i.v.; enhance protein anabolism (avoid secondary
deficiency of Ile and Val); exchange transfusion/dialysis not usually required;
Long-term: Diet (monitor Leu, Val, Ile in plasma); consider trial of thiamine
for three weeks (10 mg/kg/day; see page 153)
Range of optimal therapy: Leu 100–250 mol/l
Ile 50–150 mol/l
Val 150–250 mol/l
Progn.: Satisfactory with prompt (before the 5th day of life) and strict therapy
Other disorders involving branched-chain amino acids

$ Hyperleucine-isoleucinaemia and hypervalinaemia: Rare conditions of uncertain
relevance, may be caused by branched-chain aminotransferase deficiency
$ 3-Hydroxyisobutyryl-CoA deacylase deficiency (valine metabolism): Single patient
with dysmorphic facies, multiple vertebral anomalies, tetralogy of Fallot, cerebral
malformations; ' cysteine and cysteamine conjugates of methacrylic acid (urine)
For organic acidurias involving branched-chain amino acid metabolism: See page 65.
Disorders of phenylalanine and tyrosine metabolism
Biochemistry
Phenylalanine and tyrosine metabo- Phenylketones
Phenylalanine
lism takes place in the cytosol. A
deficiency of the enzyme phenyl- PAH
alanine hydroxylase (PAH) or the Tyrosine 4-OH-phenyl-
cofactor tetrahydrobiopterin (BH4) compounds
Aminotransferase
causes the accumulation of phenyl-
alanine which is transaminated to 4-OH-Phenylpyruvate 4-OH-phenyl-
phenylpyruvate. The cleavage of compounds
Dioxygenase
the phenolic ring is only possible by
dioxygenation of homogentisate. A Homogentisate Benzoquinone-
deficiency of the enzyme fumaryl- acetate
Dioxygenase
acetoacetase causes accumulation
of fumarylacetoacetate and Maleylacetoacetate Succinyl-
succinylacetoacetate and -acetone. acetoacetate,
These highly toxic substances Fumarylacetoacetate Succinylacetone
inhibit several enzymes including Fumarylacetoacetase
4-OH-phenylpyruvate dioxygenase
and porphobilinogen synthase and
are carcinogenic (alkylation of Fumarate Acetoacetate
DNA).
Phenylketonuria (PKU)
PKU was one of the first neurogenetic disorders identified (Følling 1934), the first
successfully treated inborn error of metabolism (Diet: Bickel 1953) and the disorder that
was instrumental for the introduction of neonatal population screening (dried blood
spots: Guthrie 1963).
Clinical: Untreated: Severe brain damage with mental retardation, seizures, spasticity
Variants: PKU: Requires diet (differences in disease severity/Phe tolerance)
MHP: Mild hyperphenylalaninaemia, does not require diet therapy (Phe
< 600 µmol/l in Germany, < 400 µmol/l in the UK, < 420 µmol/l in the USA)
”BH4-sensitive PKU”: Reduction of Phe levels after BH4 supplementation in
many patients with mild PKU (enhancement of residual activity)
Enzyme: Phenylalanine hydroxylase (PAH)
Genetics: > 400 mutations in the PAH gene, varying residual activities
(see PAH mutation database: www.pahdb.mcgill.ca)
Incidence: In Europe up to 1:4 400 (Ireland), average ~ 1:8 000
Diagn.: Neonatal screening (filter paper card), AA (plasma): ')Phe, n-& Tyr
DD: BH4 cofactor deficiency (see pages 54, 146)
Therapy: Phe-restricted diet, supplementation of essential amino acids + trace elements
(exact recommendations differ between countries; see below for the German
recommendations); BH4 supplementation is currently investigated as a
potential treatment option in mild PKU
Progn.: Normal development and intelligence with immediate and efficient treatment
Maternal PKU
Fetopathy in pregnant mothers with PKU (Phe > 360 µmol/l); strict diet treatment must
be started before conception and maintained throughout pregnancy!
German recommendations for PKU treatment

Goal: 1st–10th yr: Phe values 40–240 µmol/l (0.7–4 mg/dl)
11th–16th yr: Phe values 40–900 µmol/l (0.7–15 mg/dl)
after 16 yrs: Phe values < 1 200 µmol/l (< 20 mg/dl)
during pregnancy: Phe values 120–360 µmol/l (2–6 mg/dl)
Follow-up: 1st yr: Lab every 1–2 wks, clinical every 3 mths
nd th
2 –10 yr: Lab every 2–4 wks, clinical every 3–6 mths
th th
11 –16 yr: Lab every 4 wks, clinical every 6 mths
after 16 yrs: Lab every 2–3 mths, clinical every 6–12 mths
Tyrosinaemia type I
Clinical: Acute (neonate/infant): Severe liver failure, vomiting, bleeding, septicaemia,
hypoglycaemia, renal tubulopathy (Fanconi syndrome)
Chronic: Hepatomegaly, cirrhosis, growth retardation, rickets, haematoma,
tubulopathy, neuropathy, neurological crises (due to porphyrins)
Enzyme: Fumarylacetoacetase
Diagn.: OA (urine): (n–)' Succinylacetone (diagnostic), ' 4-OH-phenyl derivatives;
AA (plasma): (n–)' Tyr, ' Met (!); porphyrins (urine): '),-Aminolevulinic acid;
(n–)' !-fetoprotein (serum)
DD: Liver disorders, in particular “neonatal hepatitis”, respiratory chain defects,
galactosaemia, fructose intolerance, bile acid synthesis disorders
Therapy: Nitisinone (NTBC) 1(–2) mg/kg in 2 doses (inhibitor of 4-OH-phenylpyruvate
dioxygenase, blocks the accumulation of toxic metabolites; beware of ' Tyr);
Phe- + Tyr-restricted diet; liver transplantation probably not longer needed in
most patients
Progn.: With nitisinone relatively good (long-term prognosis still unclear)
Compl.s: Hepatocellular carcinoma (watch AFP), renal failure
Tyrosinaemia type II
Clinical: Painful corneal lesions (lacrimation, photophobia, scars), hyperkeratosis
(soles, palms), mild mental retardation
Enzyme: Cytosolic tyrosine aminotransferase
Diagn.: AA (plasma): '')Tyr, ' Phe; OA (urine): 4-OH-phenylpyruvate, -lactate,
-acetate
Therapy: Phe- and Tyr-restricted diet
Alkaptonuria
Clinical: Black/brown/red urine discolouration at alkaline pH; arthritis
Enzyme: Homogentisate dioxygenase
Diagn.: OA (urine): '')Homogentisic acid
Therapy: Low-protein diet
Other disorders of tyrosine metabolism

$ Tyrosinaemia type III: 4-Hydroxyphenylpyruvate dioxygenase deficiency; uncertain
clinical relevance, no skin lesions; a Phe and Tyr-restricted diet is recommended.
$ Hawkinsinuria: Unknown enzyme; doubtful clinical relevance, failure to thrive,
acidosis
Disorders of histidine metabolism
Histidinaemia
Clinical: Incidental finding, asymptomatic
Enzyme: Histidase/histidine ammonialyase
Diagn.: AA (plasma): ')His; AA (urine): ')His; ')imidazolepyruvic acid (urine)
Therapy: None
Other disorders of histidine metabolism

$ Urocanase deficiency: Probably asymptomatic; ')urocanic acid (urine)
$ Formiminotransferase deficiency: Probably asymptomatic; ')formiminoglutamic acid
(urine). Treatment with folinic acid (15 mg/day) has been tried in symptomatic
patients.
Disorders of lysine and tryptophan metabolism
Biochemistry
Tryptophan Hydroxylysine Lysine

Dioxygenase Kinase Reductase
Phospho- Saccharopine
Kynurenine
hydroxylysine Dehydrogenase
3-OH-kynurenine
2-Aminoadipic semialdehyde
Kynureninase
ort 2-Aminoadipic acid
nsp
Tra out
in/ ndria Aminotransferase
cho
2-Oxoadipic acid mito
2-Amino- 2-Oxoadipic acid
adipic acid Dehydrogenase
Glutaryl-CoA
GCDH
Crotonyl-CoA
SCHAD
Cytosol Mito-
chondrion
Acetyl-CoA
Lys is completely metabolised in the mitochondria. The initial transfer of the terminal
amino group to 2-oxoglutarate (producing glutamate) involves two enzymes and the
intermediary saccharopine. The resulting 2-aminoadipic semialdehyde is dehydro-
genated to 2-aminoadipic acid. Trp is metabolised in a complex cytosolic pathway to
kynurenine and subsequently to 2-oxoadipic acid which is converted to 2-aminoadipic
acid and transported into the mitochondrion. 2-Aminoadipic acid is converted to 2-
oxoadipic acid and subsequently by two oxidative decarboxylation steps to glutaryl-
CoA and crotonyl-CoA.
Glutaric aciduria type I

See page 67
Tryptophanaemia
Clinical: Incidental finding, asymptomatic; occasional symptoms of nicotinic acid
deficiency (as in Hartnup disease, see page 82)
Enzyme: Tryptophan-2,3-dioxygenase?
Incidence: Approx. 1:10 000
Diagn.: AA (plasma): ')Trp (400–800 µmol/l)
Therapy: Nicotinamide (50–300 mg/day)
Other disorders of lysine and tryptophan metabolism

$ Hyperlysinaemias I and II: Rare, deficiencies in the conversion of Lys to
2-aminoadipic semialdehyde; uncertain relevance
$ 2-Aminoadipic aciduria: Rare, ? deficiency of the mitochondrial import of 2-
aminoadipate; uncertain relevance; urinary oxoadipic acid may be cytosolic in origin
$ Hydroxykynureninuria: Rare, ? deficiency of kynureninase; treatment: Nicotinamide
$ Hydroxylysinuria: Rare, ? deficiency of hydroxylysine kinase; possibly associated
with mental retardation
Disorders of cytosolic methyl group transfer

and the metabolism of sulphur amino acids
Biochemistry
Folic acid
Serine
Tetrahydro- Methionine
Glycine folate
S-Adenosylmethionine
5,10 Methylene Methylation

Vitamin B12 MS
reactions
tetrahydrofolate Betaine
S-Adenosylhomocysteine
MTHFR
5-Methyl
tetrahydrofolate
Homocysteine
Serine
CBS
S-Adenosylmethionine (SAM), is the most
important methyl group donor in cellular Cystathionine
metabolism. Remethylation of homocysteine
to methionine is catalysed mainly by the Homo- CTH
methylcobalamin-(vitamin B12-)dependent serine
methionine synthase (MS) or alternatively Cysteine
betaine-homocysteine methyltransferase
(methyl group donor betaine). Methyl-
cobalamin is regenerated in the folate cycle Sulphite
involving 5,10-methylenetetrahydrofolate SO
reductase (MTHFR) and other enzymes.
The breakdown of homocysteine to cysteine Sulphate
is catalysed by the vitamin B6-dependent
enzymes cystathionine beta-synthase (CBS) und cystathionine gamma-lyase (CTH).
Cysteine is further catabolised via cysteine sulphinate (precursor of the amino acid
taurine, a component of the bile acids) to sulphite which is oxidised to sulphate by the
molybdenum-containing enzyme sulphite oxidase (SO) and excreted in the urine.
Methionine and homocysteine play a central role in cytosolic methylation transfer

required for a range of functions including the synthesis of creatine, choline and
adrenaline as well as DNA methylation. Disorders of the cytosolic methyl group transfer
frequently cause severe neurological disorders; symptoms may also be related to vascular
complications of elevated homocysteine.
Homocysteine (Hcy) and cysteine (Cys) are usually found as disulphides (homocystine
and cystine) in the extracellular space. Mild elevations of homocysteine in plasma
(centrifuge immediately) can only be detected through a specific HPLC analysis or other
specific methods. Classical homocystinuria, however, may be recognised by a positive
nitroprusside test (Brand reaction, see page 31) in the urine. Cystinosis (page 122) and
cystinuria (page 82) are caused by lysosomal and renal transport defects.
Methylenetetrahydrofolate reductase (MTHFR) deficiency

Clinical: Infantile epileptic encephalopathy; progressive psychomotor retardation,
variable progressive neurological and psychiatric presentations (especially
posterior tract lesion), thromboembolism
Diagn.: ')Hcy (> 150 µmol/l); AA (plasma): N–& Met; nitroprusside test positive
DD: Folate malabsorption
Therapy: Betaine (up to 10 g/day in 3 doses); try riboflavin (vitamin B2) 5–10 mg/day,
hydroxocobalamin (0.5–1 mg/day orally or 1 mg i.m. monthly) and folic acid
5–10 mg/day. Folinic acid (15 mg/day) may be used instead but is more
expensive
Methionine synthase deficiency, disorders of methylcobalamin synthesis

(see also methylmalonic aciduria, page 66; cobalamin metabolism, next page)
Clinical: Megaloblastic anaemia, progressive mental retardation, neurological disease,
psychiatric disturbance
Diagn.: ')Hcy (> 150 µmol/l); AA (plasma): n–& Met; OA (urine): ')methylmalonic
acid (cobalamin defects); nitroprusside test positive
Therapy: HO-cobalamin (1 mg/day–week i.m., dose depends on defect); consider
betaine (75 mg/kg/day) and folic acid 5–10 mg/day
Mild hyperhomocysteinaemia
Clinical: Risk factor (particularly in conjunction with folate deficiency) for:
rd th
$ Premature vascular disease in the 3 and 4 decade (infarctions,
thromboembolism – not relevant in childhood)
$ ' Risk for neural tube defects in maternal hyperhomocysteinaemia
Causes: $ Endogenous and exogenous disorders of folic acid or homocysteine
metabolism, especially folate deficiency + homozygosity for MTHFR
polymorphism A222V (677C>T, homozygous in up to 5% of Europeans)
$ Vitamin B12 deficiency
Diagn.: ' Total Hcy (plasma) > 15 (up to 30–40) µmol/l.
Therapy: Folic acid 5 mg/day, sometimes vitamin B6 (pyridoxine) 100 mg/day
Classical homocystinuria
Clinical: Marfan-like appearance, epilepsy, mental retardation, progressive myopia
(early symptom), lens dislocation, osteoporosis, thromboembolism
Manif.: Progressive disease, usually starting at school age
Enzyme: Cystathionine beta-synthase
Bioch.: Varying severity of enzyme deficiency,
accumulation of homocysteine % collagen disorder
Diagn.: AA (plasma): ')Met, '')Hcy (> 150 µmol/l), & Cys; nitroprusside test positive
DD: Disorders of methionine synthesis; cobalamin defects
Therapy: Pyridoxine 50–100 mg/day (+ folic acid 10 mg/day); if this has no effect: Diet,
betaine 100 mg/kg/day (if necessary up to 3 x 3 g/day), hydroxocobalamin
(1 mg/day orally, from 5 yrs of age), vitamin C (100 mg/day).
Goal: Hcy (plasma) < 30 µmol/l. (one may be doing well at 60 µmol/l).
Sulphite oxidase deficiency and molybdenum cofactor deficiency

Clinical: Infantile epileptic encephalopathy; progressive psychomotor retardation,
severe microcephaly; later: Lens dislocation
Bioch.: Molybdenum is also cofactor of xanthine oxidase (see page 141)
Diagn.: Sulphite test (fresh urine) positive; AA (plasma): ')taurine, ')sulphocysteine
& Cys, & Hcy; in molybdenum cofactor deficiency: && uric acid (serum),
'')(hypo)xanthine (purines in urine) (normal in sulphite oxidase deficiency);
enzyme studies, mutation analysis
Therapy: No specific therapy
$ Cystathioninuria (cystathionine gamma-lyase deficiency) is generally considered to

be a benign condition without pathogenetic relevance.
Disorders of cobalamin metabolism
Biochemistry
Dietary
Enterocyte Blood Lysosome Hepatocyte
cobalamin MeCbl
Intrinsic Trans-
factor cobalamin II CblIII CblII CblI AdoCbl
Mitochondrion
Dietary vitamin B12 (cobalamin, Cbl) is bound to gastric intrinsic factor (IF), absorbed
in the ileum, transported in the blood bound to transcobalamin II (TCII), taken up by
the cell, released from TCII in the lysosomes and oxidised to CblIII in the cytosol. CblIII
is further processed either to cytosolic methylcobalamin (MeCbl, cofactor of
methionine synthase, see page 75) or to mitochondrial adenosylcobalamin (AdoCbl,
cofactor of methylmalonyl-CoA mutase, see page 66).
Disorders of absorption and transport of cobalamin

The most frequent cause of cobalamin deficiency in children is poor nutrition, e.g.
prolonged breast-feeding of children when the mother herself is vitamin B12-deficient
(for instance, because of a strict vegan diet).
Inherited disorders
(a) Intrinsic factor (IF) deficiency
(b) Imerslund-Gräsbeck syndrome: Intestinal malabsorption (common in Finland)
(c) Transcobalamin II (TCII) deficiency
(d) Cobalamin malabsorption (defect of gastric Cbl release from proteins)
(e) R-protein deficiency (R-binder = glycoprotein that binds Cbl, released in stomach)
Clinical: Vomiting, failure to thrive, psychomotor retardation, megaloblastic anaemia
with hypocellular bone marrow, atrophic glossitis, progr. neuropathy/myelo-
pathy/encephalopathy; sometimes hepatosplenomegaly; (b) usually proteinuria
Manifest.: Toddlers and pre-school children; c.) in the first months of life
Diagn.: OA (Urine): ' Methylmalonic acid; (') Hcy (plasma); & TCII (c);
& cobalamin (normal in c); path. Schilling test (a, b, c), corrected by IF (a)
Therapy: OH-Cbl (CN-Cbl) 1 mg/day i.m. for 2 wks; long-term therapy 1 mg/1–3 mths;
in (a.): 1 mg once or twice weekly; folate up to 4 x 15 mg/day oral
Disorders of intracellular cobalamin metabolism

(a) CblF defect: Disorder of lysosomal cobalamin release
(b) CblC and cblD defects: Cytosolic disorders of AdoCbl and MeCbl synthesis
(c) CblA and cblB defects: Disorder of mitochondrial AdoCbl synthesis
(d) CblE and cblG defects: Disorder of MeCbl synthesis, see page 75
Clinical: (a, b) as in absorption/transport defects; (c) as in methylmalonic aciduria, see
page 66; (d) failure to thrive, psychomotor retardation, hypotonia/hypertonia,
encephalopathy/neuropathy, epilepsy, megaloblastic anaemia; see page 76.
Manifest.: First months of life, sometimes neonatal
Diagn.: OA (urine): ' methylmalonic acid (a, b, c), ' homocysteine (plasma) (a, b, d);
cobalamin and TCII normal
Therapy: OH-Cbl i.m. 1 mg/day (CN-Cbl less effective); betaine (a, b, d, see page 76);
as in methylmalonic aciduria (c, see page 66); folate up to 4 x 10 mg/day oral
Disorders of serine and glycine metabolism
Biochemistry
Glucose 3-P-Hydroxy- 3-P-Serine Serine

pyruvate Amino- PSP
3-PGDH transferase THF
3-P-Glycerate SHMT
MTHF
Glycine
Pyruvate Gly cleavage THF
P/H/T/L MTHF
NH3 + CO2
Serine is required for the synthesis of glycine, cysteine, purines, thymine and other
metabolites. It is formed from 3-phosphoglycerate (glycolysis) and may serve as a
substrate of gluconeogenesis via conversion to pyruvate. Glycine synthesis involves
the cytosolic pyridoxal phosphate-(PALP-)dependent enzyme serine hydroxymethyl-
transferase (SHMT) which employs tetrahydrofolate (THF) as a methyl group acceptor.
Ser and Gly play important roles in the folate cycle and methyl group transfer (page
75). Gly also serves as the main inhibitory neurotransmitter. It is broken down by the
mitochondrial glycine cleavage system, an enzyme complex consisting of four proteins
(P, H, T, L) and resembling the pyruvate dehydrogenase complex.
Serine deficiency disorders

Disorders of serine synthesis have only been diagnosed in very few children and the
clinical spectrum is not yet sufficiently known.
Clinical: Usually severe neurological disorder: Congenital microcephaly; psychomotor
retardation, epilepsy, spastic tetraparesis, occasionally cataract, failure to
thrive, hypogonadism
Enzymes: $ 3-Phosphoglycerate dehydrogenase deficiency; several children.
$ 3-Phosphoserine phosphatase deficiency: In one boy with Williams
syndrome (no epilepsy, normal glycine).
Diagn.: AA (CSF + plasma, fasting!): & Ser; n–& Gly; & 5-methyltetrahydrofolate in
CSF; enzyme studies (fibroblasts)
Therapy: L-serine 200–600 mg/kg/day until normalisation of L-serine. If seizures
persist add glycine up to 200 mg/kg/day. Satisfasctory outcome was achieved
by antenatal treatment in one patient.
Non-ketotic hyperglycinaemia
Clinical: Severe epileptic encephalopathy, hypotonia, progressive neurological
symptoms; neonatal onset, variants with late onset or transient disease course
Enzyme: Glycine cleavage system
Diagn.: AA (plasma, CSF): ')Gly, Gly-ratio CSF/plasma > 0.06 (normal < 0.04);
caution: borderline elevations can be caused by valproate treatment;
enzyme studies (lymphocytes, liver)
DD: Hyperglycinaemia (with ketosis): Organic acidurias (inhibition of hepatic
glycine cleavage system by pathological metabolites); prolonged fasting.
Therapy: Experimental dextromethorphan (5–20 mg/kg/day), Na-benzoate (250–750
mg/kg/day, aiming to normalise plasma glycine levels with plasma benzoate
levels below 2 000 µM); folinic acid (15 mg/day)
Progn.: Poor
Sarcosinaemia
Sarcosine is produced in the breakdown of choline via betaine to glycine.
Clinical: Incidental finding, probably no pathogenetic relevance
Enzyme: Sarcosine dehydrogenase
Diagn.: AA (plasma, urine): ')sarcosine
Disorders of ornithine and proline metabolism
Biochemistry
Cytosol
Glutamate Mitochondrion
P5C dehydrogenase P5C synthase
!1-Pyrroline-
OAT Ornithine
Proline oxidase 5-carboxylate (P5C)
Urea
cycle
P5C reductase
Proline
The concentration of ornithine, the primary carrier molecule of the urea cycle (see page
61), is regulated by ornithine aminotransferase (OAT). The reversible reaction
catalysed by this enzyme allows ornithine synthesis at times of high arginine
requirements, e.g. in the first months of life, whilst later in life it is required for
removal of dietary arginine. The intermediary product, !1-pyrroline-5-carboxylate
(P5C), may be synthesised from glutamate and is also the precursor of proline.
Gyrate atrophy of retina and choroidea

Clinical: Myopia (childhood), impaired night vision % blindness (age 40–55 yrs);
fundoscopy: Retinopathy (gyrate atrophy, increasing from the periphery)
Enzyme: Ornithine aminotransferase (OAT)
Bioch.: Disorder of ornithine removal (toxic on retinal cells)
Diagn.: NH3 normal (except occasionally in neonates); AA (plasma): ')Orn;
& creatinine
DD: Urea cycle defects (HHH syndrome)
Therapy: Pyridoxine 40–200–600 mg/day; arginine-restricted diet; consider creatine
monophosphate (up to 2 g/kg/day); Arg in hyperammonaemic neonates
Hyperprolinaemia type I
Enzyme: Proline oxidase
Diagn.: AA (plasma): ')Pro; AA (urine): ')Pro, OH-Pro, Gly
Hyperprolinaemia type II
Clinical: Associated with epilepsy, mental retardation; may be asymptomatic
Enzyme: !1-pyrroline-5-carboxylate (P5C) dehydrogenase
Diagn.: AA (plasma): '')Pro; AA (urine): ')Pro, OH-Pro, Gly; ')P5C (plasma, urine)
Therapy: Not known/not necessary
Hypoprolinaemia
Clinical: Cataract; joint hypermobility; progressive mental retardation
Enzyme: !1-Pyrroline-5-carboxylate (P5C) synthase
Diagn.: Hyperammonaemia; AA (plasma): &"Pro; & Orn; & Arg; & Cit
Disorders of amino acid transport
Several specific transport systems ensure virtually complete (re)absorption of amino

acids in the gut and kidneys. The calculation of renal tubular re-absorption shows values
- 95–99% for most amino acids. Genetic defects of these transport systems are some-
times asymptomatic and are detected only through elevation of the respective amino
acids in urine with normal (or low) values in plasma.
urine conc. (mmol/mol crea) x plasma creatinine (µmol/l)
Tubular re-absorption (%) = (1- –––––––––––––––––––––––––––––––––––––––––––– ) x 100
plasma conc. (µmol/l) x 1000
Lysinuric protein intolerance

Clinical: Failure to thrive, diarrhoea, interstitional pneumonia, osteoporosis, renal
failure, haemolysis, hyperammonaemia with progressive encephalopathy –
prevalent in Finland
Bioch.: (Re)absorption defect of the dibasic amino acids (Lys, Arg, Orn)
% interruption of the urea cycle; lysine deficiency
Diagn.: ')NH3, LDH, ferritin; AA (urine): ')Arg, Lys, Orn; AA (plasma): N–& Arg,
Lys, Orn, n-' citrulline; enzyme studies (liver)
Therapy: Citrulline substitution, protein restriction (does not correct Lys deficiency)
Cystinuria
Clinical: Nephrolithiasis (cystine crystallises above 1 250 µmol/l at pH 7.5)
Bioch.: Re-absorption defect of Lys, Arg, Orn and Cys
Diagn.: Nitroprusside test positive; AA (urine): '')Cys, ')Arg, Lys, Orn; AA (plasma):
Normal.
Carrier: AA (urine): Type I = normal; type II + III = ')Cys, Lys
Therapy: High fluid intake, also at night (> 5 l/day); alkalinisation of the urine;
in selected cases try penicillamine 1–2 g/day; consider mercaptopropionyl-
glycine or captopril
Hartnup disease
Clinical: Often asymptomatic; sometimes photodermatitis, cerebellar ataxia
Bioch.: Reabsorption defect of the neutral amino acids (Ala, Ser, Thr, Val, Leu, Ile,
Phe, Tyr, Trp, His, Gln, Asn); pathogenetically relevant: Tryptophan
deficiency % nicotinic acid and serotonin deficiency
Diagn.: AA (urine): ')neutral amino acids; AA (plasma): N–& neutral amino acids
DD: Fanconi syndrome: ')all AA including Pro (!), Gly, Arg, Lys, Orn
Therapy: Nicotinamide 50–300 mg/day; sun protection
Iminoglycinuria
Bioch.: Reabsorption defect of imino acids (Pro, hydroxyproline) and Gly
Diagn.: AA (urine): ')Pro, OH-Pro, Gly
DD: Hyperprolinaemia, hydroxyprolinaemia (AA plasma!), Fanconi syndrome
Disorders of the gamma-glutamyl cycle
Biochemistry
! -Glutamyl ! -Glu cyclotransferase
Amino acid
amino acid
5-Oxoproline
Cysteinylglycine 5-Oxoprolinase
Dipeptidase
! -Glutamyl
transpeptidase Cysteine Glutamate
Glycine ! -Glu-Cys synthetase
Amino ! -Glutamylcysteine
acid Glutathione Glutathione synthetase
extracellular intracellular
The tripeptide glutathione (Ȗ-Glu-Cys-Gly) is an essential component of cellular

metabolism. It serves as a gamma-glutamyl donor for the transport of amino acids
across membranes, releasing 5-oxoproline in the cytosol which is recycled to
glutathione (gamma-glutamyl cycle). The sulphhydryl group of the cysteinyl residue
functions as an electron donor in many reactions including the detoxification of oxygen
radicals and organic peroxides; the resulting disulphide is regenerated in the
erythrocytes by NADPH from the pentose phosphate pathway (see page 107). By
transhydrogenation, glutathione cleaves disulphide bonds in proteins, e.g. insulin,
whilst through the action of glutathione-S-transferase it binds and detoxifies various
(mostly lipophilic) compounds including cytotoxic anticancer drugs. Glutathione is
also required for the synthesis of cysteinyl leukotrienes (see also page 153).
Disturbances of the gamma-glutamyl cycle cause a range of clinical problems including

neonatal metabolic acidosis, haemolytic anaemia, electrolyte imbalances and
progressive neurological symptoms. All four known enzyme defects are inherited in an
autosomal recessive fashion; the most important disorder in this group is glutathione
synthetase deficiency. Initial investigations include the analysis of organic acids (5-
oxoproline) and glutathione status in urine, erythrocytes (see page 35), leukocytes and/or
fibroblasts. Enzyme studies are performed in erythrocytes or other nucleated cells
(leukocytes, fibroblasts), but erythrocytes only contain part of the gamma-glutamyl cycle
(no gamma-glutamyl transpeptidase and 5-oxoprolinase).
Glutathione synthetase deficiency

Clinical: Severe form: Haemolytic anaemia, metabolic acidosis, often progressive
neurological symptoms (e.g. mental retardation, seizures, ataxia, spasticity)
Mild form (erythrocytes): Haemolytic anaemia
Diagn.: OA (urine): '' 5-oxoproline; & glutathione (erythrocytes, leukocytes, fibro-
blasts); reduced synthesis of cysteinyl leukotrienes (monocytes, neutrophils,
urine); & glutathione synthetase (erythrocytes, fibroblasts), mutation analysis
DD: 5-Oxoprolinase deficiency (see below)
Secondary 5-oxoprolinuria: e.g. acute decompensation in propionic aciduria,
urea cycle defects, mitochondrial disorders, extreme prematurity, Stevens-
Johnson syndrome, intoxication (e.g. paracetamol)
Therapy: Correct acidosis (Na-bicarbonate/Na-citrate/THAM), try !-tocopherol
10 mg/kg/day (assists granulocyte function), ascorbate (100 mg/kg/day),
N-acetylcysteine, vitamin E (10 mg/kg/day); avoid drugs that may cause
haemolysis (similar to glucose-6-phosphate dehydrogenase deficiency)
Gamma-glutamylcysteine synthetase deficiency

Clinical: Haemolytic anaemia, jaundice; variable: psychosis, neuropathy, ataxia,
myopathy/muscle weakness
Diagn.: Hyperaminoaciduria; & glutathione (erythrocytes); no 5-oxoprolinuria;
& Gamma-glutamylcysteine synthetase (erythrocytes, leukocytes, fibroblasts)
Therapy: Avoid drugs that may cause haemolysis; vit. C & E may be tried
Gamma-glutamyl transpeptidase deficiency

Clinical: Variable; mental retardation, psychosis; no haematological abnormalities
Diagn.: ' Glutathione (urine); normal glutathione in erythrocytes, impaired synthesis
of LTD4, & Gamma-glutamyl transpeptidase (leukocytes, fibroblasts)
Therapy: No specific treatment available
5-Oxoprolinase deficiency
Clinical: Very variable, possibly asymptomatic; single cases with mental retardation,
urolithiasis, renal colic, colitis, diarrhoea
Diagn.: OA (urine): ' 5-oxoproline, glutathione status normal, & 5-oxoprolinase
(leukocytes, fibroblasts)
DD: Glutathione synthetase deficiency, secondary 5-oxoprolinuria (see above)
Therapy: None known
Membrane-bound dipeptidase (cysteinylglycinase) deficiency

Clinical Mental retardation, motor impairment, peripheral neuropathy, partial deafness
Diagn.: # Cystinylglycine (urine, plasma); glutathione status normal
Therapy No specific treatment available
Disorders of peptide metabolism
Prolidase deficiency
Clinical: Skin lesions (ulcerations), mild mental retardation, frequent infections
Enzyme: Prolidase = peptidase B
Bioch.: Disorder of collagen breakdown (degradation of dipeptides with N-terminal
Pro/OH-Pro)
Diagn.: Peptide analysis (urine): ')iminodipeptides; enzyme studies
Carnosinaemia
Clinical: Mental retardation, often asymptomatic
Enzyme: Carnosinase – cleaves carnosine (dipeptide "-Ala–His)
Diagn.: AA (plasma, urine): ')carnosine; enzyme studies
Therapy: None/none necessary
Homocarnosinosis
Clinical: Skin lesions (ulcerations), mild mental retardation, frequent infections
Bioch.: Disorder of collagen breakdown
Diagn.: AA (urine); enzyme studies
Therapy: None
Energy metabolism
Biochemistry: Pyruvate metabolism and the tricarboxylic acid cycle

Glucose
LDH ALT
Lactate Pyruvate Alanine
PC PDH
Aspartate AST
Acetyl-CoA
Oxaloacetate
Gluconeogenesis Citrate synthase
Malate Citrate
TCA
Fumarase cycle
Fumarate 2-Oxoglutarate
KDHC
SDH
= Complex II Succinate
The respiratory chain
Intermembrane 4 H+ 2 H+ 2 H+ 2 H+ H+
Space
CytC
Complex
Complex I Compl.
IV
CoQ 2 e- V
2 H+ Compl. II
2 e- 2 H+ 2 e-
2 e- Compl.
4 H+ III
Matrix 2 H+
1/2 O2 H 2O
FADH2 FAD 2 H+
NADH+H+ NAD+ +2H+ H+
ADP + Pi ATP
Complex I Complex II Complex III Complex IV Complex V

mtDNA 7 subunits 1 subunit 3 subunits 2 subunits
nDNA 39 subunits 4 subunits 10 subunits 10 subunits 10 subunits
One of the main functions of the mitochondrion is the supply of energy in the form of
ATP by fatty acid oxidation (see page 93), the oxidation of acetyl-CoA in the
tricarboxylic acid cycle, and oxidative phosphorylation in the respiratory chain. For
this purpose the mitochondrion contains more than 50 enzymes and enzyme complexes
that are composed of up to 40 different polypeptides. NADH originates mostly from
the TCA cycle and is oxidised by complex I whilst FADH2 is generated e.g. through
beta-oxidation of fatty acids and is oxidised by complex II. The redox reactions in
complexes I, III and IV generate a proton gradient across the inner mitochondrial
membrane that drives ATP synthase (= complex V).
Abbreviations: PDHC = pyruvate dehydrogenase complex; PC = pyruvate carboxylase,

LDH = lactate dehydrogenase, ALT = alanine aminotransferase, AST = aspartate
aminotransferase, KDHC = 2-oxoglutarate dehydrogenase complex, SDH = succinate
dehydrogenase, TCA = tricarboxylic acid cycle, CoQ = ubiquinone (coenzyme Q),
CytC = cytochrome C, mtDNA/nDNA = mitochondrial/nuclear DNA.
Energy metabolism 87
Mitochondrial disorders
Mitochondrial disorders in a strict sense are disorders of enzymes or enzyme complexes

directly involved in the generation of chemical energy by oxidative phosphorylation.
These include pyruvate dehydrogenase (PDH) complex, the tricarboxylic acid cycle, the
respiratory chain and ATP synthase. There is considerable overlap between individual
disorders with regard to clinical features, pathophysiology and genetics as some proteins
are shared by several enzyme complexes and accumulating metabolites may have an
inhibitory effect on other enzymes. Blockage of the respiratory chain due to O2
deficiency, genetic defects or inhibitors causes a rise in the NADH/NAD+ ratio which in
turn inhibits PDH and other enzymes of intermediary metabolism including the
tricarboxylic acid cycle.
Disorders that affect the cellular supply of ATP disturb numerous functions especially in
organs with a high energy requirement such as brain, skeletal muscle, heart, kidney or
retina. Patients show various combinations of neuromuscular and other symptoms
involving different, independent organ systems, sometimes explained by tissue-specific
expression of a particular genetic defect. The disease course is variable but often rapidly
progressive. There is some overlap with cerebral organic acidurias (page 67).
Respiratory chain defects can present at any age. Intra-uterine development may be
severely affected, resulting in severe dystrophy and (cerebral) malformations at birth.
Young children frequently suffer from encephalomyopathic disease whilst myopathies
predominate in the adult. Specific syndromes with typical clinical features have been
characterised but are not strictly separated, as the pattern of organs involved may change
and the molecular basis is heterogeneous and overlapping. Symptoms are often
progressive, but can be relatively static for long periods of time. Inheritance may be
recessive, dominant, X-linked or maternal with variable expression or penetrance.
Respiratory chain defects in children are often due to mutations in nuclear genes for
subunits or assembly factors (described for all complexes) which usually present within
the first five years of life. Defects of mitochondrial DNA (mtDNA), inherited in variable
distribution from the mother, are more frequently associated with specific clinical
syndromes and usually present at a later age; in children they are found in around 5–10%
of cases.
Clinical features
The clinical evaluation of a suspected mitochondrial disorder should entail (a) a full
assessment of muscle function including creatine kinase and possibly muscle ultrasound
and EMG; (b) a full neurological examination including EEG (see below for results of
neuroradiological studies); as well as (c) a detailed assessment of the function of other
organ systems. Abnormal findings may be subsumed as muscle disease, CNS disease or
multi-system disease and rated as follows.
Muscle disease
$ Progressive external ophthalmoplegia
$ Ptosis, facies myopathica
$ Exercise intolerance (abnormal fatigue, muscle aches, cramps after normal play etc.)
$ Reduced muscle power or muscular hypotonia
$ Episodes of acute rhabdomyolysis (acute muscle pain, weakness, '')CK [serum],
'')myoglobin [urine])
$ Abnormal EMG (mild myopathic changes)
CNS disease
$ Delayed or absent psychomotor development or mental retardation (IQ < 70)
$ Loss of acquired skills
$ Stroke-like episodes (transient hemianopia, hemiplegia etc.)
$ Migraine
$ Frank seizures or abnormal EEG
$ Myoclonus or myoclonic epilepsy
$ Cortical blindness
$ Pyramidal tract signs (increased muscle tone, opisthotonus etc.)
$ Signs and symptoms of extrapyramidal involvement (athetosis, dystonia etc.)
$ Signs and symptoms of brain stem involvement (autonomic disturbances, swallowing
difficulties, nystagmus, strabismus etc.)
$ Signs and symptoms of cerebellar involvement (ataxia, intention tremor,
dysdiadochokinesis etc)
Multisystem disease (suggested investigations in parentheses)

$ Blood (check blood count, reticulocytes): Sideroblastic anaemia, pancytopenia
$ Gastrointestinal tract (check liver enzymes, amylase, lipase, bilirubin, coagulation):
Acute or chronic hepatic dysfunction, failure to thrive, exocrine pancreatic
dysfunction (> 7% fat excretion), intestinal pseudo-obstruction, otherwise
unexplained chronic diarrhoea (> 3 wks)
$ Endocrine system: Short stature, delayed puberty, diabetes mellitus,
hypoparathyroidism, central diabetes insipidus
$ Heart (check ECG, echocardiography): Cardiomyopathy (in the absence of a
congenital heart defect or hypertension), conduction block
$ Kidney (check urea, creatinine, renal tubular function): Proximal tubular dysfunction
(Fanconi syndrome), focal segmental glomerulosclerosis
$ Eyes (full ophthalmological examination, consider ERG): Cataract, retinopathy, optic
atrophy
$ Hearing (appropriate tests): Sensorineural hearing loss
$ Peripheral nerves (clinical examination; check neurophysiology in case of clinical
suspicion): Peripheral neuropathy
$ General: exacerbation of listed symptoms or signs with minor illness; sudden
unexplained neonatal or infantile death in family history, feeding difficulties,
generally “not well”
A mitochondrial disorder should be strongly considered in patients with:

$ Muscular disease and involvement of two additional systems, as described above (one
of which may be CNS)
$ CNS disease and involvement of two additional systems, as described above (one of
which may be muscle)
$ Multisystem disease (at least three systems) and involvement of muscle and/or CNS
Investigations
Metabolic investigations
Elevated lactate is the major laboratory finding in mitochondrial disease and this should
be investigated through multiple measurements in blood, urine and CSF. The differential
diagnosis is discussed on page 13. It is important to note that consistently normal lactate
values do not exclude a mitochondrial disorder. Mild elevation of alanine may sometimes
be a diagnostic biochemical finding. The measurement of pyruvate is not usually helpful
for reaching a diagnosis.
$ Lactic acid in blood, measured repeatedly during the day, after periods of fasting (e.g.
overnight), before and after meals, etc.
$ CSF lactate particularly in the case of CNS involvement
$ Organic acids (urine) obtained during the day (lactate, ketones, other metabolites)
$ Amino acids in plasma and CSF (')Ala, Thr)
$ Consider glucose challenge (only when lactate is consistently normal; see page 45)
$ CSF protein (may be elevated e.g. in Kearns-Sayre syndrome)
Neuroradiological studies
Perform MRI, consider NMR spectroscopy (MRS); Cranial computed tomogram may be
indicated when calcifications are suspected
$ Leigh syndrome (MRI-T2: hyperintense lesions in putamina, globi pallidi, caudate
nuclei, brain stem)
$ Stroke-like picture (not confined to a vascular territory)
$ Leukodystrophy
$ Cerebral or cerebellar atrophy
1
$ Clearly discernible lactate peak in H-MRS of brain
31
$ Abnormal P-MRS of muscle (')inorganic phosphate (Pi), ' phosphocreatine/Pi ratio)
Surgical muscle biopsy (see also page 39)

This is the most important diagnostic investigation. It should only be carried out in a
well-equipped mitochondrial centre to avoid poor results. Some of the analyses must be
performed in muscle tissue that has not been frozen.
$ Fix for electron microscopy (mitochondrial number and morphology)
$ Freeze in liquid nitrogen, store at –70°C:
– Enzyme histochemistry (cytochrome C oxidase, SDH, ATPase)
– Immunohistochemistry (antibodies against respiratory chain polypeptides)
– Enzyme studies
– Molecular genetic studies
$ Immediately isolate native mitochondria for investigations in fresh tissue (e.g.
measurement of oxidation of 14C-labeled substrates or polarographic measurement of
O2 uptake) – only these investigations allow the recognition e.g. of transport defects
$ Fix for light microscopy
Typical abnormalities in histopathological studies:

$ Ragged red fibres or ragged blue fibres (these are not common in childhood)
$ COX-negative fibres or strongly reduced overall COX-staining (caution: technical
problems)
$ Abnormal (reduced or patchy) SDH staining or strongly SDH-reactive blood vessels
$ Abnormal mitochondria in electron microscopy
A mitochondrial disorder is probable in patients with clinical symptoms and signs

as described above and at least one of the following:
$ Typical metabolic abnormalities
$ Typical morphological changes in muscle
$ Typical neuroradiological abnormalities
(A proposal for diagnostic criteria of mitochondrial disorders in infants and children has
been published by Wolf & Smeitink [2002] Neurology 59: 1402–5)
Further investigations when a specific diagnosis is suspected

Molecular studies
Mitochondrial lactic acidaemia in early childhood is usually caused by mutations in
nuclear genes, and mtDNA analysis may not necessarily be indicated. Mutation analysis
of nuclear genes is only indicated after a biochemical defect has been delineated.
Investigating mtDNA is particularly useful in patients with clinical features compatible
with a specific syndrome (e.g. mtDNA depletion, Pearson, NARP, MELAS, MERRF).
Frequently, mtDNA mutations are present only in a proportion of mitochondria
(heteroplasmy). Disease-causing mtDNA mutations are not always found in blood
(except for LHON) but may be restricted to muscle tissue.
Additional studies
$ Barth syndrome: Consider tetralinoleyl cardiolipin in thrombocytes
$ MNGIE: Thymidine in urine/plasma, thymidine phosphorylase activity in leukocytes
Treatment
Treatment options in primary mitochondrial disorders are limited and of doubtful
effectiveness. If the clinical condition does not improve with various treatment regimens
within half a year, it is justified to stop them with clinical follow-up.
General measures
$ Ensure adequate intake of energy, fluids and electrolytes
$ Restrict glucose intake, add lipids (1–2 g/kg/day) when fatty acid oxidation disorders
have been excluded
$ Avoid/treat conditions with high energy consumption:
– Treat fever efficiently
– Treat seizures/epilepsy efficiently, avoid valproate
$ L-Carnitine 50–100 mg/kg/day (after exclusion of fatty acid oxidation disorder; check
carnitine status)
$ Avoid drugs that may inhibit the respiratory chain (e.g. valproate, tetracyclines,
chloramphenicol)
Treat acidosis
Use sodium bicarbonate; use THAM buffer if sodium is high (or dialysis).
Note: Dichloroacetate may lower lactate levels by blocking inactivation of PDH but still
is of doubtful clinical value and has serious side effects.
Try vitamins and cofactors to support mitochondrial function

$ Idebenone or coenzyme Q10 5–10 mg/kg/day
$ Biotin 20 mg/day
$ Creatine 100–200 mg/kg/day in isolated mitochondrial myopathy
There is insufficient evidence that other vitamins of cofactors may be helpful.
Pyruvate dehydrogenase complex (PDHC) deficiency

This multi-enzyme complex consists of components E1 (decarboxylase, tetramer of two
proteins ! and .), E2 (acyltransferase), E3 (dihydrolipoamide dehydrogenase) and E3BP
(E3-binding protein, protein X) and requires thiamine pyrophosphate, !-lipoic acid, FAD,
NAD+ and CoA as cofactors. Structure is conserved and some protein components (e.g.
E3) are identical in all oxoacid dehydrogenases (including BCKDH, see page 73).
Clinical: Psychomotor retardation, muscular hypotonia, epilepsy, ataxia, apnoea,
progressive encephalopathy (including Leigh syndrome, focal brain stem
lesions); brain malformations; not usually (cardio)myopathy; rarely liver
disease. Boys are more frequently and more seriously affected than girls.
Variants: Most frequently deficiency of subunit E1!;
Dihydrolipoamide dehydrogenase deficiency: Subunit E3 of mitochondrial
dehydrogenase complexes (pyruvate, 2-oxoglutarate, branched chain !-
oxoacids); biochemical findings of maple syrup urine disease (page 73)
Genetics: E1!: X-chromosomal semi-dominant inheritance
Diagn.: ' lactate (' pyruvate, normal lactate/pyruvate ratio) in various body fluids;
enzyme studies (fibroblasts, muscle)
Therapy: Usually not very effective; try ketogenic diet, thiamine (500–2 000 mg/day;
see also page 153)
Progn.: Poor
Disorders of the tricarboxylic acid cycle

$ 2-Oxoglutarate dehydrogenase complex (KDHC) deficiency: Extrapyramidal signs,
hepatopathy; high urinary levels of 2-oxoglutaric acid
$ Fumarase deficiency (fumaric aciduria): Progressive encephalopathy, sometimes
prenatal onset: Severe psychomotor retardation, hypotonia, opisthotonia, visual
failure, vomiting; progressive brain atrophy. High urinary levels of fumaric acid. No
known treatment.
Leigh syndrome
Subacute necrotising encephalomyelopathy; occurs as an independent syndrome in the
1st–2nd year of life, may be caused by different primary mitochondrial disorders.
Clinical: Psychomotor retardation or regression, muscular hypotonia, brain stem signs
(especially strabismus and swallowing difficulties), ataxia, pyramidal signs,
optic atrophy, nystagmus, etc.; acute deterioration after common infections
possible
MRT: Bilateral fluctuating symmetrical hypodensities, symmetric T2 hyperintensity
of basal ganglia and brain stem, may be fluctuating
Genetics: mtDNA mutations 8993T>C or T>G (NARP mutation), SURF1 mutations
(complex IV deficiency) and various other nuclear genes (particularly
complex I deficiency), also in PDHC deficiency
Histol.: Progressive focal necroses, vascular proliferation and gliosis in basal ganglia,
brain stem, cerebellum and periventricular tissue
Important other syndromes
Clinical features Onset Genetic defect

(age)
Barth Cardiomyopathy, neutropenia, myopathy Neonate Taffazin (X-linked)
(ƃ)
Sengers Congenital cataract, cardiomyopathy, Neonate Unknown
myopathy
mtDNA Dystrophy, failure to thrive, gastro- Neonate– Several: Nucleoside
depletion oesophageal reflux, hypoglycaemia, liver 2 yrs kinase, DNA poly-
dysfunction/failure, myoclonic epilepsy, merase gamma etc.
ataxia, encephalopathy, infect-associated (aut. rec. and aut.
deterioration dom.)
Progressive myopathy Infancy Thymidine kinase
st
Pearson Anaemia/pancytopenia, exocrine 1 yr Large deletions of
pancreatic dysfunction, liver dysfunction, mtDNA, sporadic
failure to thrive, later development of
Kearns-Sayre syndrome
Wolfram Diabetes insipidus, diabetes mellitus, optic 1–2 yrs WFS1 gene (aut.
atrophy, deafness (DIDMOAD) rec.)
Alpers Progressive neuronal degeneration 2–4 yrs Heterogeneous,
(sometimes epilepsia partialis continua) usually aut. rec.
and liver involvement
MELAS Encephalomyopathy, lactic acidosis, 5–15 yrs 3243A>G (tRNALeu
stroke-like episodes, small stature, gene) and others
migraine, diabetes mellitus
MERRF Myoclonic epilepsy with “ragged red 5–15 yrs 8344G>A (tRNALys
fibres” (RRF); encephalomyopathy, gene) and others
neuropathy, progr. dementia
MNGIE Myo-neuro-gastro-intestinal encephalo- 5–15 yrs Multiple deletions,
pathy: Episodes of intestinal pseudo- mtDNA depletion,
obstruction, neuropathy, myopathy, CPEO thymidine phos-
phorylase deficiency
Kearns- CPEO, retinopathy, ptosis, deafness, con- 5–30 yrs Always mtDNA:
Sayre duction disturbances, ataxia. Multi-system Large deletions /
(KSS) disease may develop. High CSF protein. duplications
NARP Neuropathy, ataxia, retinitis pigmentosa 5–30 yrs 8993T>G/C (ATPase
gene) and others
LHON Leber’s hereditary optic neuroretinopathy. 12–30 11778G>A and
Painless visual loss. Males more often yrs others; usually
affected than females homoplasmic
CPEO Chronic progressive external 15–40 Usually single
opthalmoplegia yrs mtDNA deletions*
*CPEO: Identification of multiple mtDNA deletions or mtDNA depletion indicates
a primary nuclear gene deficiency, which may be autosomal dominant
(e.g. polymerase gamma deficiency).
Biochemistry: Fatty acid oxidation and the metabolism of ketone bodies
Long-chain fatty acids

Transporter Transporter
Acyl-CoA synthetase
Cytosol Carnitine
Acyl-CoA
CPT1 Carnitine
Intermembrane space Translocase shuttle
Acyl-CoA CPT2
Mitochondrion
VLCAD
ETF ETF-QO Respiratory
MCAD
SCAD chain
LCEH
Acyl-CoA Crotonase
Beta-
wwwwwwwwwwwwwwwwww
oxidation 3-Hydroxyacyl-CoA
LCHAD Respiratory
MCHAD? chain
LCKAT SCHAD
TCA
Acetyl-CoA MCKAT
cycle ȕ-Oxo-
thiolase
Acetoacetyl-CoA
HMG-CoA Synthase
Ketogenesis 3-HMG-CoA SCOT
HMG-CoA Lyase (extrahepatic)
Ketone bodies Acetoacetate 3-OH-Butyrate

Acetone
Mitochondrial oxidation of fatty acids (FA) is one of the major sources of cellular
energy, providing up to 80% of the total requirement during fasting. The brain is
unable to fully oxidise fatty acids but can adapt to the catabolism of ketone bodies
synthesised by the liver. During fasting or prolonged exercise, long-chain fatty acids
(C16–C20) stored as triglycerides in fat tissue are released by lipases and activated to
acyl-CoA esters. The inner mitochondrial membrane is not permeable for long-chain
fatty acids which are transported into the mitochondria via the carnitine shuttle. Carni-
tine is transported into the cell (and reabsorbed in the kidney) by a carnitine transporter
(except in hepatocytes). Several chain-length specific enzymes shorten acyl-CoA by
two carbon atoms (one acetyl-CoA) in subsequent ȕ-oxidation cycles. Long-chain
compounds are metabolised at the inner mitochondrial membrane, medium and short-
chain compounds in the mitochondrial matrix. Acetyl-CoA enters the tricaboxylic acid
(TCA) cycle or is converted to ketone bodies. Protons generated by dehydrogenases are
transferred to the respiratory chain. Extrahepatic ketolysis requires succinyl-CoA:3-
oxoacid CoA-transferase (SCOT).
Enzyme abbreviations: See description of individual disorders.
Disorders of fatty acid oxidation and ketogenesis
Clinical features
Disorders of fatty acid oxidation and ketogenesis can present with great variability.
Insufficient ketone body production in combination with inhibition of gluconeogenesis
by low acetyl-CoA during catabolic states (prolonged fasting, surgery, infection etc.) may
cause the typical hypoketotic hypoglycaemic coma which may be accompanied by signs
of liver failure with hyperammonaemia. The first manifestation is freqently in late
infancy. Accumulation of toxic long-chain acylcarnitines particularly in long-chain fatty
acid oxidation disorders may cause severe neonatal lactic acidosis, cardiomyopathy and
hepatopathy resembling a respiratory chain defect. Milder deficiency variants of long-
chain fatty acid oxidation and the carnitine shuttle may affect skeletal muscle and become
manifest in adolescence or early adulthood as chronic weakness, pain or recurrent
rhabdomyolysis, or cause acute or chronic cardiomyopathies. The renal excretion of large
amounts of acylcarnitines can lead to secondary carnitine deficiency. All disorders in this
group are inherited in an autosomal recessive fashion though heterozygotes can
occasionally express symptoms.
Diagnosis
The simultaneous determination of serum concentrations of free fatty acids and ketones
(3-hydroxybutyrate) is essential for rapid recognition of fatty acid oxidation disorders in
acute hypoglycaemia. Acylcarnitine analysis is usually diagnostic; normal results despite
hypoketotic hypoglycaemia may be suggestive of HMG-CoA synthase deficiency.
Organic acid analyses and serum carnitine studies may be helpful. Enzyme studies
(leukocytes, fibroblasts) and molecular studies confirm the diagnoses and allow family
investigations. Challenge tests (fasting test, oil challenge) are indicated only in selected,
exceptional cases and should only be carried out in specialised metabolic centres (danger
of acute cardiotoxicity and other complications!).
$ Acute: See page 6 – investigations during symptomatic hypoglycaemia

$ Clinical chemistry: & Glc, n–')liver enzymes, NH3, lactate, CK, myoglobin
$ Free fatty acids and ketones (plasma, serum): Normal values see page 158
$ Carnitine status (serum):)& total carnitine (may be elevated in acute crisis),
' acylcarnitine/total carnitine ratio;
in CPT1 deficiency ' free and total carnitine, & acylcarnitine
$ Acylcarnitines (filter paper card): Specific metabolites, rapid diagnosis, but carnitine
transporter may give borderline results
$ Organic acids (urine): Specific dicarboxylic acids arising from microsomal
#-oxidation of fatty acids; specific acylglycines in some disorders; ketostix not
always negative
$ Enzyme studies (fibroblasts, lymphocytes)
$ Molecular studies may be helpful in several disorders, particularly MCAD and
LCHAD deficiencies (common mutations)
$ Histology: Often fatty degeneration, lipid myopathy
Treatment
$ Avoid fasting > 8–12 hrs (may already be too long); frequent (preferably low-fat, rich
in carbohydrates) meals, early intervention in gastroenteritis, etc.
$ Acute: High dose glucose i.v. (7–10 mg/kg/min), if necessary add insulin, keep blood
glucose at 5.5 mmol/l (100 mg/dl). Excessive glucose may increase lactic acidosis.
$ Carnitine supplementation in carnitine deficiency (100 mg/kg/day) (avoid in
disorders of long-chain fatty acid oxidation or the carnitine cycle – long-chain
acylcarnitines are cardiotoxic)
$ Do not give intravenous lipids. Give medium-chain triglycerides (MCT) in proven
disorders of long-chain fatty acid oxidation
$ In proven disorders of long-chain fatty acid oxidation and the carnitine cycle:
Acute: Dialysis, exchange transfusion;
long-term: Medium-chain triglycerides; experimental: D,L-3-hydroxybutyrate
$ In ETF deficiency or SCAD deficiency: Try riboflavin 150 mg/day
Carnitine transporter deficiency

(primary carnitine deficiency, carnitine uptake deficiency)
Clinical: Same as above, cardiomyopathy, cardiac failure, muscle weakness, liver
disease
Bioch.: Intracellular carnitine deficiency (muscle), carnitine depletion due to deficient
renal reabsorption
Diagn.: Serum: &&& Total carnitine (< 5–10% normal); urine: N–')free carnitine;
acylcarnitines: Usually &&)all compounds;
OA (urine): No (few) dicarboxylic acids
Therapy: Carnitine 100 mg/kg/day, check serum levels and adjust
Carnitine palmitoyltransferase I (CPT1) deficiency

Clinical: Same as above, severe liver disease, no (cardio-)myopathy; renal tubular
acidosis
Diagn.: Carnitine status: N–')total/free carnitine, < 20% acylcarnitine;
acylcarnitines: N–')free carnitine, & C16, C18, C18:1;
OA (urine): No dicarboxylic aciduria
Carnitine translocase (carnitine acylcarnitine carrier) deficiency

Clinical: Same as above, severe cardiomyopathy, arrhythmias, liver disease
Diagn.: Serum: && Total carnitine, 80–100% acylcarnitine;
acylcarnitines: '')C16, C18, C18:1, & free carnitine;
OA (urine): ± Dicarboxylic aciduria
Carnitine palmitoyltransferase II (CPT2) deficiency

Clinical: Same as above, cardiomyopathy, liver disease; mild form (age > 15 yrs) with
episodic muscle weakness, myoglobinuria, rhabdomyolysis (e.g. during fever)
Diagn.: Serum: & Total carnitine, 40–80% acylcarnitine;
acylcarnitines: ' ratio (C16 + C18:1)/(C2);
OA (urine): No/non-specific dicarboxylic acids
(Very) long-chain acyl-CoA dehydrogenase (VLCAD) deficiency

The enzyme VLCAD at the inner mitochondrial membrane catalyses the oxidation of
long-chain acyl-CoA; the enzyme “LCAD” that was originally thought to have this
function is present in cells in much lower concentration and also catalyses the oxidation
of branched long-chain acyl-CoAs. The physiological role of LCAD remains unknown.
Clinical: Same as above, cardiomyopathy, liver disease, hepatomegaly, SIDS; late onset
recurrent rhabdomyolysis
Diagn.: Acylcarnitines: ')C14:1, ratio C14:1/C12:1; OA (urine): C6–C14 dicarboxylic acids
Mitochondrial trifunctional protein (MTP) deficiency,

long-chain hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency
MTP consists of Į- and ȕ-subunits encoded by two genes; it mediates hydratase (LCEH),
dehydrogenase (LCHAD) and oxothiolase (LCKAT) activities. LCHAD function is
primarily affected in the majority of patients (common mutation E510Q, HADHA gene).
Clinical: Same as above, cardiomyopathy, liver disease, muscular hypotonia,
neuropathy, retinopathy; late onset recurrent rhabdomyolysis; mothers of an
affected fetus may develop steatosis or HELLP syndrome in pregnancy
Diagn.: ' Lactate (3-hydroxypalmitoyl-CoA inhibits PDH);
acylcarnitines: ')Hydroxy compounds C14-OH, C16-OH, C18-OH, C18:1-OH;
OA (urine): C6–C14 (hydroxy-) dicarboxylic acids; mutation analysis (E510Q)
Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency

MCAD deficiency is the most common fatty acid oxidation disorder in Northern Europe
(incidence up to 1:6 000) due to a prevalent mutation K329E in the ACADM gene. It is
now widely recognised in neonatal screening.
Clinical: Reye-like, often rapidly progressive metabolic crisis after 8–12–16 hrs fasting,
during ordinary illness, after surgery, etc.: Lethargy, nausea, vomiting (often
with normal blood sugar) % within 1–2 hrs coma, seizures, cardiac arrest.
No primary muscle involvement, frequently asymtopmatic
Variant: Mild deficiency frequently found by neonatal screening (associated with
mutation Y67H), of uncertain clinical relevance
Manif.: Any age, most frequently 4 mths to 3 yrs, but also neonates
Diagn.: Acylcarnitines:)')C8, C6, ')ratio C8/C10; OA (urine): C6–C10 dicarboxylic acids,
suberylglycine, hexanoylglycine; mutation analysis (K329E)
Therapy: Avoidance of fasting; there is some controversy with regard to the need of
carnitine supplementation (50–100 mg/kg/day – necessary only in proven
deficiency)
Progn.: Excellent after diagnosis. First crisis has been fatal in up to 25% of cases;
often residual neurological damage
Short-chain acyl-CoA dehydrogenase (SCAD) deficiency

Clinical: Metabolic acidosis, progressive psychomotor retardation, hypotonia,
occasionally myopathy (older patients); rarely hypoglycaemia
Variant: Mild deficiency caused by two common polymorphisms, uncertain relevance
Diagn.: Acylcarnitines: ')C4; OA (urine): Ethylmalonic acid (see page 68),
butyrylglycine; enzyme studies, mutation analysis
Short-chain hydroxyacyl-CoA dehydrogenase (SCHAD) deficiency

Clinical: Hyperinsulinaemic hypoglycaemia, see page 110.
Multiple acyl-CoA dehydrogenase deficiency (glutaric aciduria type II)

Deficient electron transfer from the FAD-dependent dehydrogenases to the respiratory
chain due to genetic defects of the electron transfer flavoprotein (ETF) or ETF-coenzyme Q-
oxidoreductase (ETF-QO); does not only affect fatty acid oxidation but also dehydro-
genases involved in the metabolism of amino acids (e.g. Val, Leu, Ile, Trp, Lys).
Clinical: Facial and cerebral malformations, cystic renal disease, Reye syndrome,
metabolic acidosis, hypoglycaemia, progressive encephalopathy, epilepsy,
(cardio-)myopathy
Diagn.: Acylcarnitines: ' all compounds C4–C18; OA (urine): ' lactic, glutaric,
ethylmalonic, dicarboxylic acids, etc.; enzyme studies
Therapy: Avoidance of fasting. Low-fat diet. Try riboflavin 150 mg/day. Experimental:
D-3-hydroxybutyrate
Progn.: Neonatal presentation usually fatal in the first weeks of life
HMG-CoA synthase deficiency

Clinical: Acute hypoketotic hypoglycaemia, relatively short fasting tolerance
Diagn.: OA (fasting urine): Dicarboxylic aciduria without ketosis; mutation analysis
(OA, acylcarnitines etc. normal outside fasting; enzyme studies no option)
Therapy: Same as in fatty acid oxidation defects
Progn.: Excellent when fasting is avoided
HMG-CoA lyase deficiency

3-Hydroxy-3-methylglutaryl-(HMG-)CoA lyase is required for ketogenesis (see page 93)
as well as for the last step of leucine oxidation (see page 64).
Clinical: Acute hypoketotic hypoglycaemia, metabolic acidosis, liver disease, often
fatal in Reye-like crisis
Diagn.: OA (urine): Specific metabolites (3-HMG, 3-methylglutaconic acid, etc.)
Therapy: Acute: Same as in organic acidurias (see page 60), carnitine, high-dose
glucose i.v.
Long-term: Low-fat (approx. 25% of daily energy requirement) protein-
restricted diet, carnitine substitution
Progn.: Good, if no residual damage from first manifestation
Disorders of ketolysis
For the differential diagnosis of ketosis see page 12. Failure to utilise ketone bodies
synthesised in the liver causes severe ketoacidosis and hyperketotic hypoglycaemia.
Succinyl-CoA:3-oxoacid-CoA transferase (SCOT) deficiency

Clinical: Recurrent episodes of severe ketoacidosis, tachypnoea, hypotonia, coma
Manif.: Neonatal period or infancy
Diagn.: ' Ketones (D-3-hydroxybutyrate) in serum and urine, persistent in fed state,
excessive in fasting; mutation studies, enzyme studies;
OA (urine):)' ketones, otherwise non-specific; acylcarnitines normal
3-Oxothiolase (mitochondrial acetoacetyl-CoA lyase) deficiency

The enzyme is also required for the metabolism of the ketogenic amino acid isoleucine
(see page 64) and the disorder is in effect an organic aciduria with excessive ketosis.
Clinical: Acute episodes of nausea, vomiting, % coma, residual neurological
abnormalities
Diagn.: ' Ketones (D-3-hydroxybutyrate) in serum and urine, relatively high blood
glucose, (lactic) acidosis, n–$ NH3
Acylcarnitines: Tiglylcarnitine, 2-methyl-3-hydroxybutylcarnitine and others;
OA (urine): ' 2-methyl-3-hydroxybutyrate, 2-methylacetoacetate, tiglyl-
glycine; consider Ile challenge (100 mg/kg, collect urine for 8 hrs % OA)
Disorders of creatine biosynthesis
The creatine/creatine-phosphate system serves as a cytosolic storage buffer of chemical

energy in brain and muscle. Disorders of creatine biosynthesis or transport cause
psychomotor retardation, speech impairment and epilepsy due to cerebral creatine
deficiency. Low creatine concentrations in the brain may be recognised by NMR spectro-
scopy (MRS); abnormal concentrations of creatine/creatinine and its precursor
guanidinoacetate may be found in serum and urine.
Guanidinoacetate methyltransferase (GAMT) deficiency

Clinical: Psychomotor retardation, autism, path. EEG, epilepsy, extrapyramidal
movement disorder
Diagn.: & Creatine/creatinine (urine), ')guanidinoacetate (plasma, urine, CSF);
&& creatine (MRS brain)
(allopurinol test may be pathological)
Therapy: Creatine 400 mg/kg/day. Dietary reduction of accumulating guanidino acetic
acid (GAA) by ornithine supplementation (which may be combined with
arginine restriction)
Biochemistry
Arginine Glycine Liver,
Pancreas
AGAT SAM SAH
Guanidino-
Ornithine acetate
Creatine
GAMT
Creatine
CRTR uptake
Creatinine Creatinine Creatine

(Urine)
CK
Brain, Creatine-
Muscle phosphate
Creatine is synthesised in a two-step process involving arginine-glycine amidinotrans-
ferase (AGAT) and guanidinoacetate methyltransferase (GAMT); S-Adenosyl-
methionine (SAM) serves as methyl donor. A creatine transporter (CRTR) is required
for creatine uptake into brain and muscle.
Arginine:glycine amidinotransferase (AGAT) deficiency

Clinical: Psychomotor retardation
Diagn.: & Guanidinoacetate (plasma, urine), n–& creatine/creatinine (urine);
&& creatine (MRS brain)
Therapy: Creatine 300–400 mg/kg/day
Creatine transporter deficiency

This recently recognised disorder appears to be a common cause of X-linked mental
retardation, with or without epilepsy.
Clinical: Psychomotor retardation, (mild) seizures that respond well to treatment
Genetics: X-chromosomal disorder
Diagn.: ')Creatine/creatinine, normal guanidinoacetate (urine);
&& creatine (MRS brain); mutation studies
Therapy: No effective therapy in hemizygotes; creatine 500 mg/kg/day may be
beneficial in symptomatic females
Carbohydrate metabolism
Biochemistry: Carbohydrate metabolism
Lactose, glycosylated Epimerase

macromolecules Branching enzyme
UDP-Gal UDP-Glc
Glycogen synthase
Galacto-
GALT Glycogen
kinase Debranching enzyme
Galactose Gal-1-P Glc-1-P
Phosphorylase
Endopl. Ret.
Galactitol
Glc-6-P‘ase
T T
Glc-6-P Glucose
Glucokinase
Hexokinase
Fru-6-P
Sorbitol
Phosphofructokinase
Fructo-
kinase
Fructose Fru-1-P Fru-1,6-bis-P
Aldolase B Fructose-1,6-bisphosphatase
Dihydroxy- Glycer-
acetone-P aldehyde-P
Glycero-
kinase
Glycerol Glycerol-3-P
Glycerolipids Phospho- PEPCK Oxalo-
Malate
enolpyruvate acetate
Mitochondrion T
Alanine
Oxalo-
PC Malate
Lactate Pyruvate acetate
LDH
PDH TCA cycle
Glucose is the most important rapid source of energy. It is catabolised to pyruvate by

cytosolic glycolysis, transported into the mitochondrion and completely oxidised in the
TCA (tricarboxylic acid) cycle, generating chemical energy. The reversible reduction
of pyruvate to lactate allows anaerobic glycolysis. In gluconeogenesis, pyruvate is
carboxylated (by pyruvate carboxylase, PC) to oxaloacetate which is transported via
the malate shuttle into the cytosol and used for the synthesis of glucose-6-phosphate
(Glc-6-P). Enzymes involved include phosphoenolpyruvate carboxykinase (PEPCK)
and fructose-1,6-bisphosphatase (aldolase A). The conversion of Glc-6-P into glucose
takes place in the endoplasmic reticulum and involves several transport systems in
addition to the enzyme glucose-6-phosphatase (Glc-6-P’ase).
Carbohydrate metabolism 101
Glycogen synthesis (from Glc-6-P) and storage takes place mostly in liver and muscle.
Storage diseases may be caused by defective enzymes in glycogen synthesis (glycogen
synthase and “branching enzyme”), glycogenolysis (tissue-specific phosphorylases,
“debranching enzyme”, lysosomal glucosidase) and glycolysis (phosphofructokinase,
etc.).
Lactose (Gal-Glc disaccharide) in milk and milk products is cleaved in the gut and
absorbed. Complete oxidation of galactose first requires activation and conversion into
UDP-glucose by galaktokinase, galactose-1-phosphate uridyltransferase (GALT) and
UDP-galactose-4-epimerase, leaving the carbon structure intact. The last step is re-
versible and UDP-galactose can be synthesised by all cells for the glycosylation of
macromolecules or to produce lactose. Defects of galactose metabolism may cause
increased production of galactitol and cataract due to accumulation in the lens.
Fructose is a component of table sugar (sucrose, Glc-Fru disaccharide) and is

contained in large amounts in fruits and various vegetables; fructose, sucrose and
sorbitol (metabolised mainly via fructose) are also frequent food additives. The
irreversible phosphorylation of fructose by fructokinase yields fructose-1-phosphate
which is cleaved by aldolase B into phosphorylated C3-metabolites that enter glycolysis
or gluconeogenesis.
Glycerol-3-phosphate is a substrate for the synthesis of triglycerides, phospholipids,

sphingolipids and other glycerolipids. It is closely linked to the glycolysis pathway via
dihydroxyacetone phosphate; the glycerol-3-P dehydrogenase reaction is catalysed by
different enzymes in the mitochondrion (FAD-dependent, irreversible), cytosol and
peroxisome (NAD+-dependent, reversible) and plays an important role in the transport
of reducing equivalents between different cellular compartments (glycerol-3-P shuttle).
Glycerol-3-P is also generated by glycerokinase-mediated activation of glycerol
(resulting from glycerolipid breakdown) in liver, kidney and gut mucosa.
Disorders of galactose and fructose metabolism
Patients with a disorder of galactose or fructose metabolism develop clinical symptoms

only after intake of lactose (milk, milk products) or fructose/sucrose, respectively, in the
diet. The presence of reducing substances in the urine (see page 30) is an important first
clue to the diagnosis; galactosaemia is also detected through neonatal screening in many
countries. Galactose-1-phosphate (Gal-1-P) and fructose-1-phosphate (Fru-1-P) which
accumulate in classical galactosaemia and hereditary fructose intolerance are toxic
particularly for the liver, kidneys and brain.
Essential fructosuria
Enzyme: Fructokinase
Hereditary fructose intolerance

Clinical: After weaning or supplementary food: Vomiting, apathy, coma, progr. liver
dysfunction with hepatosplenomegaly, hypoglycaemia, renal tubular dysfunc.,
failure to thrive, aversion to fructose-containing foods/sweets, no caries
Enzyme: Aldolase B
Genetics: Incidence 1:20 000; rel. common mutation A149P in the aldolase B gene
Bioch.: Toxic effect due to reduced intracellular ATP, inhibiton of glycogenolysis
Diagn.: Renal tubular damage: ' Glc, albumin, AA, reducing substances (urine);
positive effect of withdrawing fructose; mutation analysis (three common
mutations); enzyme studies (liver); sialotransferrin electrophoresis.
Intravenous fructose challenge has previously been used as a primary
diagnostic test but i.v. fructose is currently (2004) not available. Oral fructose
challenge has not been evaluated, is unpleasent for the patient and may have
serious complications.
Therapy: Strict fructose-restricted diet, vitamin supplements
Classical galactosaemia
Clinical: Progr. symptoms after start of milk feeds, usually starting on the 3rd or 4th day:
Vomiting, diarrhoea, jaundice, disturbances of liver function, sepsis % death
from hepatic and renal failure; increasing bilateral cataract
Enzyme: Galactose-1-phosphate uridyltransferase (GALT)
Genetics: GALT gene, numerous mutations; incidence in Europe 1:18 000–180 000
Var.: Duarte 1 allele (mutation N314D + L218L) = $ enzyme activity;
Duarte 2 allele (N314D + deletion in 5'UTR of the GALT gene; allele
frequency up to 10%) = 50% enzyme activity, no diet required
Diagn.: See pages 35, 53 ( neonatal screening)
' Gal and Gal-1-P (serum, erythrocytes, dried blood spots); enzyme studies;
mutation analysis;
renal tubular damage: ' Glc, albumin, AA, reducing substances (urine)
Therapy: After obtaining blood sample (see page 53): Lactose-free infant formula (may
be life-saving); lactose-free, galactose-restricted diet throughout life:
Galactose intake pro day (mg): Infants 50(–200), toddlers 150(–200), school
children 200(–300), adolescents 250(–400), adults 300(–500)
Target: Gal-1-P (erythrocytes) 2–4 mg/dl (up to 5 mg/dl – low values may be
difficult to reach in early childhood due to high endogenous Gal production)
Compl.s: Oro-motor and more generalised dyspraxias, mental retardation, ataxia,
tremor; ovarian dysfunction with abnormal pubertal development (girls)
Galactokinase deficiency
Clinical: Rapidly progressive central cataract, reversible in the first weeks of life
Diagn.: ' Gal, galactitol, glucose (urine), low Gal-1-P (blood); enzyme studies
Therapy: Lactose-free diet
UDP-galactose epimerase deficiency

Clinical: Similar to classical galactosaemia; psychomotor retardation
Diagn.: ' Gal and Gal-1-P (serum, erythrocytes) but normal GALT activity; enzyme
studies (erythrocytes)
Therapy: Same as in classical galactosaemia
Disorders of gluconeogenesis
A typical feature of the disorders in this group is recurrent hypoglycaemia with lactic
acidosis ± ketosis. Severe hypoglycaemia and hepatomegaly are found especially in
enzyme defects which are close to glucose in the gluconeogenesis pathway (G6Pase and
FBPase deficiencies), whilst progressive neurodegeneration and lactic acidosis are
leading features of enzyme defects that are closer to the tricarboxylic acid cycle (PEPCK
and PC deficiencies). Glucose-6-phosphatase (G6Pase) deficiency belongs to the
glycogen storage diseases (type I, see page 104).
Pyruvate carboxylase deficiency

The synthesis of oxaloacetate from pyruvate is not only necessary for gluconeogenesis
from lactate or alanine, it also allows the removal of citrate, 2-oxoglutarate or succinyl-
CoA from the tricarboxylic acid cycle for the biosynthesis of various compounds and is
required for the synthesis of aspartate which is used in the transport of reducing
equivalents across the mitochondrial membrane and in the urea cycle.
Clinical: Mild form (type A): Psychomotor retardation, mild lactic acidosis;
Severe form (type B): Severe neonatal lactic acidosis, encephalopathy, coma,
seizures, hypotonia, mild hypoglycaemia, renal tubular acidosis
Diagn.: ')Lactate, pyruvate, ketones, NH3; n–$ lactate/pyruvate ratio but
% 3-OH-butyrate/acetoacetate ratio; AA (plasma): $ Cit, Ala, Lys, Pro;
OA (urine): 2-oxoglutaric acid, etc.; enzyme studies (fibroblasts)
DD: Multiple carboxylase deficiency (see page 69)
Therapy: Doubtful efficacy: Biotin 10–40 mg/day, carbohydrate-restricted diet, consider
succinate 2–10 g/day
Phosphoenolpyruvate carboxykinase deficiency

Clinical: Hypotonia, hepatomegaly, failure to thrive, lactic acidosis, hypoglycaemia
Fructose-1,6-bisphosphatase deficiency
Clinical: Acute crisis (often neonatal) with hepatomegaly (but normal transaminases),
acidosis, hyperventilation, ketose, hypoglycaemia, coma, seizures, brain
damage
Diagn.: ')Lactate, pyruvate, ketones; OA (urine): 2-oxoglutaric acid
Therapy: Usually responds rapidly to treatment with intravenous/oral glucose ± sodium
bicarbonate
Glycogen storage diseases
Glycogen storage diseases usually present either with pathological glycogen storage (e.g.
isolated hepatomegaly) and corresponding organ dysfunction (e.g. liver disease, myo-
pathy), or with hypoglycaemia. Depending on the (often organ-specific) enzyme defect,
there may be primary hepatopathic (types I, IIIb, IV, VI, IX), myopathic (types V, VII) or
mixed (types II, IIIa) symptoms. All glycogen storage diseases except some forms of type
VI (X-linked) are autosomal recessive; the cumulative incidence is approx. 1:20 000. The
diagnosis is confirmed by biopsy + enzyme studies or mutation analysis; specific
challenge tests (fructose, galactose, glucose, glucagon) are indicated in exceptional cases
only.
Glycogen storage disease type I (von Gierke)

Enzyme: Glucose-6-phosphatase or transport systems of the endoplasmic reticulum
Organ: Liver, kidney
Clinical: Hypoglycaemic seizures, recurrent hypoglycaemia with acidosis, “doll face”,
truncal obesity, failure to thrive, hepatomegaly, nephromegaly, muscle
atrophy, small stature, bleeding tendency
Manif.: 3–6 mths, sometimes later
Var.: GSD1 non-a: Neutropenia (< 1 500/µl), leukocyte dysfunction, bacterial
infections, diarrhoea, inflammatory bowel disease
Diagn.: & Glucose, ' lactate, ' triglycerides, ' uric acid, (') transaminases;
OA (urine): 2-oxoglutaric acid, etc.; glucose challenge: Fall in lactate;
mutation analysis; enzyme studies (liver)
Therapy: Avoid hypoglycaemia by means of continuous carbohydrate intake:
$ Frequent meals (every 2–3–4 hrs): Slowly resorbed carbohydrates (glucose
polymer/maltodextrin, starch), no sucrose, limited fructose (vegetables,
fruits), avoid lactose; soy-based milk replacement products + calcium
$ Nights: Continuous (> 10 hrs) intake of glucose polymer/maltodextrin via
nasogastric tube, start as soon as possible after last daytime meal; consider
uncooked corn-starch in adults
Allopurinol if required;
type Ib/c: Add Filgrastim (G-CSF, Neupogen®) 2–3 µg/kg/day s.c. (exclude
myelodysplasia by bone marrow biopsy), higher if necessary
Monitor: Keep blood sugar above 80 mg/dl (4.4 mmmol/l) throughout the day; aim for
blood lactate < 1.5 mmol/l, urinary lactate < 0.06 mmol/mol creatinine, normal
triglycerides, uric acid, normal liver function tests; yearly ultrasound scan of
the liver, check kidney function regularly after age 14
Compl.s: (After 2nd–3rd decade): Liver tumours, osteoporosis, renal failure
Glycogen storage disease type II (Pompe)

Enzyme: Lysosomal acid maltase (!-glycosidase) $ lysosomal disorder (storage of
cholesterol esters and triglycerides)
Organ: Generalised
Clinical: Infantile: Failure to thrive, severe (cardio)myopathy with hypotonia, resp.
failure, usually fatal in the first year; juvenile/adult: Slowly progressive
muscle weakness (only skeletal muscle); sometimes atherosclerosis
Diagn.: Pathological pattern of oligosacharides (urine); vacuolated lymphocytes; other
metabolic investigations normal (lysosomal enzyme); typical ECG + echo;
enzyme studies (leukocytes, fibroblasts, muscle, liver; caution: “Renal” acid
maltase may cause false negative results), mutation analysis
Therapy: Symptomatic; physiotherapy; protein-enriched nutrition with supplementation
of Ala and Leu; experimental enzyme replacement therapy
Glycogen storage disease type III (Cori/Forbes)

Enzyme: “Debranching enzyme” = amylo-1,6-glucosidase
Organ: Liver, heart, muscle
Clinical: Similar to type I, but “milder”, normal kidney size; type IIIa: Progressive
(cardio-)myopathy; type IIIb: Only liver disease; rarely tubulopathy
Diagn.: & Glucose; AA (plasma): & Ala, Leu, Ile, Val; ' transaminases; ' cholesterol;
glucose challenge: Rise in lactate
enzyme studies (leukocytes, fibroblasts or liver/muscle)
Therapy: Maintain normoglycaemia
Glycogen storage disease type IV (Andersen)

Enzyme: “Branching enzyme” = amylo-1,4%1,6-transglucosylase
Organ: Liver, muscle
Clinical: Liver disease % cirrhosis, liver failure; splenomegaly, usually fatal by age 4
Diagn.: Liver biopsy; enzyme studies (leukocytes, fibroblasts or liver/muscle)
Therapy: Experimental liver transplantation
Glycogen storage disease type V (McArdle) and type VII (Tauri)

Enzyme: Muscle phosphorylase (type V); muscle phosphofruktokinase, etc. (type VII)
Clinical: Exercise: Rapid fatigue, muscle cramps
Manif.: Adolescents–adults; type VII: Children
Diagn.: Serum: ' uric acid, CK; myoglobinuria; ischaemia test: ' NH3, no rise in
lactate (see page 52)
DD: Long-chain fatty acid oxidation defects; respiratory chain defects; muscle-
AMP desaminase deficiency
Therapy: Avoid excessive exercise
Glycogen storage disease type VI (Hers) and IX

Enzyme: Liver phosphorylase (type VI), liver phosphorylase kinase (type IX)
Clinical: Hepatomegaly, mild hypoglycaemia, often asymptomatic
Manif.: Childhood, symptoms may improve with puberty
Diagn.: & Glucose, ' lactate, ' transaminases; glucose challenge: Rise in lactate;
enzyme studies (erythrocytes, leukocytes, liver/muscle)
Genetics: Mostly X-linked (subunit of liver phosphorylase), otherwise recessive
Therapy: Often not necessary; maintain normoglycaemia
Glycogen storage disease type 0

Enzyme: Glycogen synthase
Clinical: During fasting: Recurrent hypoglycaemia with ketosis, ' lactate; no organo-
megaly
Bioch.: & Glycogen
Diagn.: Glucose challenge: Rise in lactate; glucagon challenge; enzyme studies (liver);
molecular genetics
DD: Ketotic hypoglycaemia
Fanconi-Bickel disease (glycogen storage disease type XI)

Enzyme: Glucose transporter 2 (GLUT2); see also page 108
Clinical: Renal Fanconi syndrome, (% rickets), aminoaciduria, phosphaturia,
glucosuria, small stature, malabsorption, hepatomegaly/nephromegaly,
fasting hypoglycaemia, glucose/galactose intolerance
Diagn.: Mutation analysis
Therapy: Frequent feeds and the use of slowly absorbed carbohydrates
Disorders of glycerol metabolism
Glycerol intolerance
Clinical: Triggered by catabolism, stress, glycerol intake: Sweating, lethargy % coma,
hypothermia, hypoglycaemia, sometimes seizures
P'genesis: Unknown
Therapy: Fat-restricted (= glycerol-restricted) diet
Glycerokinase deficiency
Clinical: Juvenile form: Recurrent vomiting, acidosis, lethargy % coma, hypothermia,
hypoglycaemia; benign/adult form: asymptomatic
Genetics: X-linked inheritance (Xp21)
Variants: Contiguous gene syndrome (large deletion within Xp21 region) % congenital
adrenal hypoplasia / Duchenne muscular dystrophy; with mental retardation,
typical facies, Addison disease, sometimes OTC deficiency
Diagn.: OA (urine): ' glycerol (DD contamination with baby cream, etc.; may be
incidental finding without clinical relevance); pseudohypertriglyceridaemia
(if triglycerides are quantified by glycerol measurement after lipolysis)
Therapy: Fat-restricted (= glycerol-restricted) diet; treatment of associated conditions
Disorders of pentose metabolism
Biochemistry
Glucose-6-P
L-Arabinose, NADP+
L-Arabitol
L-Xylulose NADPH+H+
D-Xylose
Xylitol D-Ribulose-5-P
Epimerase Isomerase
Nucleotide
D-Xylulose D-Xylulose-5-P D-Ribose-5-P
biosynthesis
Transketolase
D-Arabitol
D-Arabinose Transaldolase
Glyceraldehyde-3-P Fructose-6-P
The pentose phosphate pathway is required for the biosynthesis of ribose (and conse-
quently nucleotides) and the regeneration of NADPH/H+ from NADP+ (required for
various biosynthetic reactions as well as reduction of glutathione, see page 83). L-
arabinose and xylose are exogenous in origin (high concentration in fruit).
Ribose-5-P isomerase deficiency

Clinical: One patient with progressive leukoencephalopathy, ataxia, mild peripheral
polyneuropathy
Diagn.: MRS (brain), polyol analysis (plasma, urine, CSF): ' Ribitol, D-arabitol
Transaldolase deficiency
Clinical: One patient with hepatosplenomegaly & liver cirrhosis
Diagn.: Polyol analysis (urine): ' Ribitol, D-arabitol, erythritol; enzyme studies
Other disorders of pentose metabolism

These conditions may be accidentally discovered through a positive test of reducing
substances in the urine. The exact pentose may be determined through urinary thin-layer
chromatography of monosaccharides and disaccharides or gas chromatographic analysis
of pentoses and polyols. Essential and alimentary pentosuria are known to be benign
conditions whilst L-arabinosuria has only been described in a single patient.
Essential pentosuria (xylitol dehydrogenase deficiency): ' L-Xylulose
Alimentary pentosuria: ' Urinary xylose & arabinose after excessive fruit intake
L-Arabinosuria (? arabitol dehydrogenase deficiency): ' L-arabinose, L-arabitol
Disorders of glucose transport
A considerable number of specific transporters are involved in the transport of glucose

and other monosaccharides across cellular membranes. Transporters of the GLUT family
enhance passive diffusion in various tissues whilst SGLT transporters mediate active
transfer coupled to an electrochemical gradient for sodium in organs where complete
resorption is necessary (kidneys and intestines). GLUT transporters may be involved in
the development of diabetes mellitus but conclusive evidence for this is still lacking.
GLUT1 deficiency
Glucose transport protein deficiency (epileptic encephalopathy, progressive micro-
cephaly, mental retardatation), see page 149
GLUT2 deficiency
Fanconi-Bickel disease (glycogen storage disease type XI), see page 106
SGLT1 deficiency: Glucose-galactose malabsorption

Clinical: Severe neonatal diarrhoea % fluid and electrolyte imbalance, dehydration
Diagn.: Mild glucosuria, pathological glucose/galactose tolerance tests, normal
fructose tolerance test
Therapy: Total parenteral nutrition; dietary replacement of glucose/galactose with
fructose
SGLT2 deficiency: Renal glucosuria

Clinical: Benign glucosuria with normal blood glucose
Therapy: None
Congenital hyperinsulinism (CHI)
Biochemistry: Regulation of insulin secretion

K+ Ca++
!
KATP VDCC
Glucose Glut 2 Glucose
K+ Ca++
Glucokinase
!
Glycolysis
Elevated
ATP/ADP ratio Insulin !
Pancreatic GDH
Glutamate 2-Oxoglutarate
beta-cell
Leucine !
Glucose is transported by Glut2 (see also page 106) into the pancreatic &-cell and
enters glycolysis via glucokinase (rate-limiting enzyme). The resulting increase in the
ATP/ADP ratio triggers exocytosis of insulin through a complex mechanism involving
closure of the KATP channel (which consists of the sulphonylurea receptor SUR1 and
subunit Kir6.2), depolarisation of the cell membrane, activation of voltage-dependent
calcium channels (VDCC) and calcium influx. The intracellular ATP/ADP ratio may
also rise with increased oxidation of glutamate to 2-oxoglutarate mediated by
glutamate dehydrogenase (GLDH). By this mechanism, leucine as an allosteric
activator of GLDH may also increase insulin secretion.
Congenital hyperinsulinism (old term “nesidioblastosis”) is the most common cause of

persistent hypoglycaemia in early childhood (differential diagnosis see page 6).
Diagnosis
$ Consistently insulin > 3 mU/l with blood sugar < 2.0 mmol/l (40 mg/dl)
$ ' Glucose requirement (> 10 mg/kg/min)
$ During hypoglycaemia: & Ketone bodies, & FFA (serum), normal blood gases and
lactate, ketostix negative, n–' NH3
$ Mutation analysis (complex especially for SUR1)
$ Important: Distinguish diffuse vs. focal/adenomatous (relevant for therapy)
$ Transient hyperinsulinism in the neonate (diabetic fetopathy, asphyxia, sepsis, rhesus
incompatibility, etc.)
$ Beckwith-Wiedemann syndrome (macrosomia, macroglossia, omphalocele, lateral ear
lobe creases)
$ Hyperinsulinism is also found in association with CDG type Ib (page 131), Usher
syndrome Typ 1c and other syndromes
Therapy
$ Central line, high glucose infusion (10–25 mg/kg/min)
$ Diazoxide (15 mg/kg/day in 3 doses); effect usually within up to 5 days, may cause
severe cardiac failure;
Consider additional hydrochlorothiazide (2 mg/kg/day in 2 doses)
Caution: High number of diazoxide non-responders, esp. in neonates
$ Alternatives: Somatostatin (1–5 µg/kg/hr i.v.); for long-term management consider
octreotide (3–20 µg/kg/day s.c. in 3–4 doses)
$ In acute situations: Glucagon (1 mg/day [5–10 µg/kg/hr] i.v.) continuously over 2–3
days
$ A trial with nifedipine (0.5–2 mg/kg/day) may be justified in selected cases.
$ If conservative therapy is ineffective: Refer to specialist centre urgently for
investigation (PET); subtotal-total pancreatic resection (90–95%).
Congenital hyperinsulinism variants
Protein Inheritance Clinical features/therapy

SUR1 Aut. recessive, Usually early manifestation and severe disease course,
rarely aut. dom. pancreatic resection often required
Kir6.2 Aut. recessive Rare, severe disease course
Gluco- Aut. dominant Good response to diazoxide
kinase
GLDH Aut. dominant Hyperinsulinism-hyperammonaemia syndrome (hyper-
ammonaemia 100–200 µmol/l, usually asymptomatic, may
be prominent early but may disappear later in childhood);
often leucine-sensitive;
Therapy: Protein-restricted diet, good response to diazoxide
SCHAD Aut. recessive Intermittent unpredictable hypoglycaemia with seizures,
good effect of diazoxide; acylcarnitines: ' C4-OH-carnitine;
OA (urine): ' 3-OH-glutarate
Focal congenital hyperinsulinism

Special form of congenital hyperinsulinism
P'genesis: Typical loss of heterozygosity (loss of maternal 11p15 allele in hyperplastic
pancreatic islands) demasking of a paternally inherited SUR1-mutation
Diagn.: L-DOPA-PET scan of pancreas; previously selective catheterisation of
pancreatic veins with simultaneous measurements of glucose and insulin
Therapy: Selective pancreatic resection after identification of adenomatous areas
Lysosomal metabolism 111
Lysosomal metabolism
Biochemistry
Lysosomes are required for the intracellular breakdown of various molecules and
compounds of all sizes. For this purpose they contain a range of hydrolases in an acidic
environment (pH 5). Some lysosomal enzymes are secreted and taken up by other cells
through endocytosis and can therefore be measured in body fluids.
Genetic defects of lysosomal enzymes cause the accumulation of incompletely

catabolised substrates within the organelle and progressive impairment of the function of
affected cell systems (e.g. connective tissue, solid organs, cartilage, bone and, above all,
nervous tissue). The cell and consequently the whole organ “swells”, causing typical
organomegaly and other morphological features.
Mucopolysaccharidoses (MPS) are disorders in the breakdown of glycosaminoglycans

(GAG). These are long chains of sulphated or acetylated amino sugars attached to a
protein skeleton. They constitute the viscous extracellular matrix. Oligosaccharidoses are
disorders in the breakdown of complex carbohydrate side-chains of glycosylated proteins
(glycoproteins, see also CDG page 131); this group also includes sialidosis (clinically
defined as mucolipidosis type I, see below). Sphingolipidoses are disorders in the
breakdown of membrane lipids that contain ceramide (composed of sphingosine and a
long-chain fatty acid) attached to a polar residue. Sphingolipids are found particularly in
the nervous system and include cerebrosides, sulphatides, sphingomyelin, trihexoside,
gangliosides and others. Mucolipidoses comprise clinical features of mucopolysaccharid-
oses and sphingolipidoses and are typically caused by a deficiency of several lysosomal
enzymes due to import defects (deficient phosphorylation in the Golgi apparatus). Lyso-
somal storage disorders include the lipid storage diseases (including the ceroid
lipofuscinoses), glycogen storage disease type II (see page 105) and lysosomal transport
defects.
Typical findings in lysosomal storage diseases

Note: The clinical manifestations are generally variable
Pathol. Oligosaccharides

Vacuolated lymphocytes
Peripheral neuropathy
Coarse facial features
GAG (urine) elevated

Cardiac involvement
Dysostosis multiplex
Myoclonic seizures
Mental retardation
Enzyme studies in:

Corneal clouding
Cherry-red spot
Angiokeratoma
Hydrops fetalis
Organomegaly
Macroglossia
Spasticity
Mukopolysaccharidoses
MPS type I ++ ++ + ++ ++ + ++ + L/F
MPS type II ++ (+) + ++ + + + S/l/F
MPS type IIIa (+) (+) (+) ++ + + (+) L/F
MPS type IIIb (+) (+) (+) ++ + + (+) S/L/F
MPS type IIIc (+) (+) (+) ++ + + (+) L/F
MPS type IIId (+) (+) (+) ++ + + (+) L/F
MPS type IVa + + + + (+) (+) L/F
MPS type IVb + + + (+) + (+) (+) L/F
MPS type VI (+) + + ++ + ++ + L/F
MPS type VII + + + + + + (+) + + S/L/F
MPS type IX + ? ? ? + L/F
Oligosaccharidoses
Fucosidosis ++ (+) (+) ++ + + (+) + + + L/F
&-Mannosidosis ++ + + ++ (+) (+) ++ + + L/F
"-Mannosidosis + + + + (+) + L/F
Asp.glucosaminuria + (+) (+) + (+) (+) (+) (+) + L/F
Schindler + + + + L/F
Sialdidosis type I + + ++ + ++ + + F
Sialidosis type II ++ (+) + ++ (+) (+) + ++ + + + F
Legend
++ = prominent feature, + = often present, (+) = sometimes present
$ Angiokeratoma = red to dark blue lesions (< 1 mm, slightly hyperkeratotic, do not
blanche on pressure) mostly on buttocks, genitalia, lower trunk, thighs)
$ Cherry-red spot – in the macula region
$ Cardiac involvement = cardiomyopathy, valve lesions, coronary artery disease
$ Vacuolated lymphocytes = typical vacuoles or evidence of storage in lymphocytes
F = fibroblasts, L = leukocytes, S = serum, M = muscle
Pathol. oligosaccharides

Vacuolated lymphocytes
Peripheral neuropathy
Coarse facial features
GAG (urine) elevated

Cardiac involvement
Dysostosis multiplex
Myoclonic seizures
Mental retardation
Enzyme studies in:

Corneal clouding
Cherry-red spot
Angiokeratoma
Hydrops fetalis
Organomegaly
Macroglossia
Spasticity
Sphingolipidoses
GM1 gangliosidosis ++ + + ++ (+) + + + ++ (+) + + L/F
GM2 gangliosidosis (+) ++ + + ++ + L/F
Galactosialidosis ++ ++ ++ ++ + (+) + (+) + + + + + F
Metachr. l‘dystr. ++ + ++ (+) L/F
Niemann-Pick A,B ++ + (+) + (+) (+) + F
Gaucher type I + + L/F
Gaucher type II + ++ + + + + L/F
Gaucher type III + + (+) (+) (+) + L/F
Fabry + + S/L/F
Krabbe ++ + ++ (+) L/F
Farber + + + (+) (+) F
Mult. sulphatase d. ++ ++ ++ ++ ++ + + (+) + + + L/F
Mucolipidoses
Mucolipidosis II + ++ + ++ + ++ + + S/L/F
Mucolipidosis III (+) (+) (+) (+) ++ + S/L/F
Mucolipidosis IV + + + + + F
Lipid storage diseases

Niemann-Pick C&D (+) + (+) + F
Wolman + + (+) (+) + L
Lysosomal transport defects

Cystinosis (+) + L
Sialic acid storage (+) (+) (+) + + (+) + + -
Neuronal ceroid lipofuscinoses (including Batten disease)

Infantile + + + (+) L/F
Late infantile + + + (+) L/F
Juvenile + (+) +
Adult + (+) (+) (+)
Glycogen storage disease type II

Pompe (page 105) + ++ + + + L/F/M
Diagnosis
There is substantial clinical overlap between different disorders and the age of
manifestation may be variable.
Symptoms and signs

$ Chronic progression of symptoms without acute metabolic crises
$ In the neonatal period often (but not always) unremarkable; sometimes hydrops
fetalis, dysmorphic facies, cardiomegaly
$ Initially often muscular hypotonia, motor delay and later mental retardation
$ Progressive organomegaly (liver, spleen, heart)
$ Coarse facial features, skeletal changes, skin changes
$ Ataxia, hyperexcitability, spasticity in neurological storage disorders
$ Cherry-red spot in the macula region in some disorders
Investigations
$ Examine skeleton (X-ray pelvis; dysostosis multiplex?)
$ Examine parenchymatous organs (ultrasound) and heart (ECG, echo)
$ Check eyes (retina, macula, lens, cornea), hearing; consider cranial MRI scan
$ Check for vacuoles in leukocytes (reliably found only in immediate blood smear; do
not use blood from an EDTA tube!), bone marrow cells or biopsies
$ Analyse glycosaminoglycans and oligosaccharides in the urine
$ If indicated, measure enzyme activities in leukocytes or fibroblasts
$ Check Chitotriosidase activity (serum, dried blood spot)
Chitotriosidase is a chitinolytic enzyme and marker of monocyte/macrophage activation.

It is highly elevated in several lysosomal storage disorders including Gaucher and
Niemann Pick C diseases and may be used for screening as well as monitoring of
treatment.
Note: false negative results in patients homozygous for a common null allele of the
CHIT1 gene (6% of Caucasians). Chitotriosidase activity is also increased in a large
number of non-metabolic conditions including atherosclerosis, sarcoidosis, beta-
thalassaemia or malaria.
Curative therapy
$ Bone marrow transplantation has proven benefit in presymptomatic patients in some
disorders (e.g. MPS I, late-onset Krabbe, metachromatic leukodystrophy) but not in
others (MPS III, MPS IV).
$ Enzyme replacement therapy in Gaucher, Fabry and MPS I is licensed and available
in Europe. Clinical trials are in progress for MPS II, MPS VI and Pompe.
Mucopolysaccharidoses (MPS)
Children with MPS usually appear normal at birth but (in most MPS) subsequently
develop progressive skeletal deformities including typical coarse facies, bone dysplasias
and contractures as well as hepatomegaly. Depending on the MPS type there may be
progressive psychomotor retardation with loss of acquired skills, corneal clouding and
deafness. Hernias and recurrent upper and lower respirator tract infections are common.
All MPS except type II (X-linked) are autosomal recessive. The diagnosis is primarily by
the analysis of glycosaminoglycans (GAG, previously called mucopolysaccharides) in the
urine (caution: Screening tests may give false negative results, particularly in types III
and IV) and confirmed by enzyme analysis. Bone marrow transplantation has proven
benefit in presymptomatic patients with MPS I and anecdotal benefit in a few patients
with MPS II and VI. For the other MPS, treatment is largely symptomatic.
Pathological glycosaminoglycans in different MPS

Mucopolysaccharidosis Typical clinical findings,
Normal
affected organ systems

I II III IV VI VII IX
Dermatan sulphate ++ ++ ++ + Skeleton + internal organs
Heparan sulphate + + + n–+ Mental retardation
Keratan sulphate + Skeleton
Chondroitin sulphate + (+) + ++
MPS type I (Hurler, Scheie)

Enzyme: !-L-Iduronidase (allelic mutations)
Clinical: Hurler: Severe form, onset in first year; hydrocephalus; fatal within 10–20 yrs
Scheie: Milder form, onset in adolescence and adulthood: Firm skin, stiff
joints, mild skeletal deformities; normal height and intelligence
There are also intermediate forms
Diagn.: ' GAG (urine); GAG electrophoresis; enzyme studies (leukocytes, fibroblasts)
Therapy: Enzyme replacement therapy for non-cerebral manifestations
MPS type II (Hunter)

Enzyme: Iduronate-2-sulphatase (X-linked)
Clinical: Similar to Hurler disease, no corneal clouding
Var.: Milder variant = type B
MPS type III (Sanfilippo)

Enzyme: 4 different enzymes of heparan sulphate metabolism (% types A–D)
Clinical: Severe encephalopathy with relatively minor organ involvement: Normal
height, fewer skeletal deformities; progressive psychomotor retardation
(delayed speech), aggressive and extremely hyperkinetic behaviour %
tetraspasticity. Important differential diagnosis in infants with relatively
non-specific mental retardation and behavioural problems.
Manif.: Age 3–4 % tetraspasticity by age 10–30
Diagn.: (') GAG (urine); GAG electrophoresis; enzyme studies (leukocytes,
fibroblasts)
MPS type IV (Morquio)

Enzyme: 2 different enzymes of keratan sulphate metabolism (% types A + B)
Clinical: Normal intelligence, small stature, severe skeletal deformities
Diagn.: n–' GAG (urine); GAG electrophoresis; enzyme studies (leukocytes,
fibroblasts)
MPS type VI (Maroteaux-Lamy)

Enzyme: N-Acetylgalactosamine-4-sulphatase (arylsulphatase B)
Clinical: Normal intelligence, skeletal deformities similar to Hurler disease
Manif.: From age 2 onwards; often macrocephaly at birth
Therapy: Enzyme replacement therapy
MPS type VII (Sly)

Enzyme: .-Glucuronidase
Clinical: Usually like Hurler disease, dysostosis multiplex, hepatosplenomegaly; broad
spectrum (hydrops fetalis 0 almost normal)
MPS type IX (Natowicz)

Enzyme: Hyaluronidase
Clinical: One patient reported with short stature and multiple painful periarticular soft-
tissue masses
Oligosaccharidoses
Oligosaccharidoses clinically resemble the MPS but are less common. Skeletal
deformities and coarse facies may range from severe to mild. There is usually
psychomotor retardation, often with progressive neurological symptoms and seizures.
Hepatomegaly, deafness and corneal clouding may be absent; some disorders (especially
the sialidoses) show a cherry-red macula spot. Early manifestation is more frequent than
in the MPS: Some disorders present at birth or in the first year (hydrops fetalis,
cardiomegaly) and are often fatal within a few years (or earlier). Severity may vary
greatly depending on the individual mutation. Disturbed oligosaccharide metabolism is
also found in GM1 and GM2 gangliosidoses and galactosialidosis.
Fucosidosis
Enzyme: !-Fucosidase
Clinical: Progressive mental retardation, mild to severe psychomotor retardation, mild
to severe hepatosplenomegaly
Diagn.: Oligosaccharides (urine); enzyme studies (leukocytes, fibroblasts)
!-Mannosidosis
Enzyme: !-Mannosidase
Clinical: Progressive mental retardation; deafness, cataract, corneal clouding,
hydrocephalus, progressive ataxia, dysostosis multiplex, hernias,
hepatomegaly; frequent bacterial infections
Progn.: Type I: Rapidly progressive, fatal within first decade
Type II: Retardation starts in childhood or adolescence
"-Mannosidosis
Enzyme: .-Mannosidase
Clinical: Mental retardation, peripheral neuropathy, angiokeratoma (adults)
Progn.: Relatively benign course
Aspartylglucosaminuria
Enzyme: Aspartylglucosaminase
Clinical: Delayed speech, behavioural abnormalities, mental retardation, mild
hepatosplenomegaly
Schindler disease
Enzyme: !-N-Acetylgalactosaminidase (= !-galactosidase B)
Clinical: Psychomotor retardation, neurodegeneration, myoclonic epilepsy
Sialidosis
This disease is traditionally classified as mucolipidosis type I but is essentially an oligo-
saccharidosis. In combination with .-galactosidase deficiency: Galactosialidosis (p. 119).
Enzyme: Sialidase (!-neuraminidase)
Clinical: Type I: & vision, myoclonic seizures, abnormal gait; cherry-red spot
Type II: Variable, dysostosis multiplex
Diagn.: Oligosaccharides (urine); enzyme studies (fibroblasts)
Sphingolipidoses
Sphingolipids (see page 111) are found throughout the body but are of special import-
ance in the nervous tissue. Galactocerebroside, sulphatides and sphingomyelin are
essential components of myelin sheaths; gangliosides are found particularly in the grey
matter of the brain. Sphingolipidoses thus usually present with primary disturbances in
the central or peripheral nervous system; in addition, sphingolipids frequently accumulate
in the reticuloendothelial system or other cells. Typical clinical features include
progressive psychomotor retardation, neurological problems, specifically epilepsy as
well as ataxia und/or spasticity. Hepatosplenomegaly is not uncommon, dysmorphy or
skeletal deformities are rare (exept in GM1 gangliosidosis). Some disorders show a
cherry-red macula spot, foam cells in the bone marrow or vacuolated lymphocytes.
Neurological and neuroradiological findings are not always specific; some sphingo-
lipidoses may be detected by oligosaccharide analysis in the urine. Clinically distinct
lysosomal leukodystrophies are the metachromatic leukodystrophy and Krabbe disease.
GM1 Gangliosidosis
Enzyme: .-Galactosidase
Clinical: Type I: Early hypotonia, psychomotor retardation, hepatosplenomegaly
Type II: Ataxia;
Type III: Variale; dystonia, normal intelligence or mental retardation;
cherry-red spot (50%, only during course of disease);
Manif.: Neonatal onset: Rapidly fatal in infancy; later onset variable with predominant
neurodegeneration + cherry-red spot or predominant dysostosis; juvenile/adult
forms without skeletal symptoms
Diagn.: Vacuolated lymphocytes (not always); oligosaccharides (urine);
enzyme studies (leukocytes, fibroblasts)
GM2 Gangliosidosis (Tay-Sachs, Sandhoff)

Enzyme: .-Hexosaminidases A and B
Clinical: Macrocephaly, neurodegeneration, psychomotor regression, startle reaction %
spastic tetraparesis, decerebration; cherry-red spot (infantile forms),
sometimes retinopathy (juvenile forms);
hepatosplenomegaly may be found in Sandhoff disease
Manif.: Infants, fatal in 2–4 yrs; also juvenile/adult forms
Diagn.: Vacuolated lymphocytes (Sandhoff disease, not always); oligosaccharides
(urine); enzyme studies (leukocytes, fibroblasts)
Galactosialidosis
Enzyme: Combined deficiency of .-galactosidase and sialidase due to defective
lysosomal stabiliser protein
Clinical: Dysostosis multiplex, hepatosplenomegaly, cardiac involvement, somatic and
psychomotor retardation, deafness, myoclonic epilepsy, ataxia; cherry-red
spot, corneal clouding (prolonged courses), sometimes retinopathy;
angiokeratomas (juvenile/adult forms)
Manif.: Severe forms: Hydrops fetalis, rapidly fatal; also infantile/juvenile/adult forms
Diagn.: Vacuolated lymphocytes; oligosaccharides (urine);
enzyme studies (fibroblasts)
Metachromatic leukodystrophy (MLD)

Enzyme: Sulphatidase = arylsulphatase A
Clinical: Lysosomal leukodystrophy: Spasticity (equinus position of the feet), neuro-
pathy, psychomotor regression (loss of ability to walk) % tetraspasticity;
often ' CSF protein; & nerve conduction velocity
Manif.: 1st–2nd yr, fatal in 3–6 yrs; juvenile (age 6–8) and adult forms
Bioch.: Central and peripheral demyelination
Diagn.: Enzyme studies (DD: Pseudo-deficiency [& amount of enzyme protein]);
')Sulphatides (urine)
Variants: $ Multiple sulphatase deficiency: See page 120.
$ Sulphatide activator (saposin) deficiency: Specific biochemical analyses,
')Sulphatides (urine); enzyme studies (leukocytes, fibroblasts);
nerve biopsy may be helpful
Niemann-Pick disease type I (= type A, B)

Enzyme: Sphingomyelinase
Clinical: Type A: Feeding problems, dystrophy, lung infiltrates, hepatosplenomegaly
%)neurological deterioration, deafness, blindness; cherry-red spot (50%);
Type B: Milder course
Manif.: Severe forms: Neonatal onset, fatal within 2 yrs
Diagn.: Foam cells “Niemann-Pick cells” in bone marrow,
enzyme studies in fibroblasts (leukocytes less reliable)
Gaucher disease
Enzyme: Glucocerebrosidase
Clinical: Type I: Hepatosplenomegaly, anaemia, bleeding tendency, abdominal pain;
skeleton: Osteopenia, pain, deformities; no CNS involvement; manifestation
in infancy to adulthood
Type II: With CNS involvement: Ophthalmoplegia, spasticity, % CNS
degeneration; hepatosplenomegaly; rapidly progressive in infancy
Type III: Milder course with CNS involvement, often hepatosplenomegaly
Diagn.: ' Acid phosphatase; “Gaucher cells” in bone marrow; enzyme studies
(leukocytes, fibroblasts); chitotriosidase (also for monitoring)
Therapy: Enzyme replacement (primarily in visceral disease); splenectomy in case of
mechanical problems.
Fabry disease
Enzyme: Ceramide trihexosidase = !-galactosidase A (X-linked)
Clinical: Pain/paraesthesias in the limbs, angiokeratomas, angiectasis, hypohidrosis;
hypertrophic cardiomyopathy, renal failure; stroke; normal intelligence
Manif.: Adolescence to adulthood (female carriers may also show symptoms)
Diagn.: Enzyme studies (plasma, serum, leukocytes or fibroblasts);
often false negative results in heterozygous women
Therapy: Enzyme replacement
Krabbe disease (globoid cell leukodystrophy)

Enzyme: .-Galactocerebrosidase
Clinical: Lysosomal leukodystrophy: Disorder of central and peripheral nervous system;
irritability, increasing spasticity, % blindness, deafness, neuropathy,
decerebration; & nerve conduction velocity
Manif.: Infancy, fatal within 1–2 yrs (10% juvenile forms)
Diagn.: ' CSF protein concentration (not in late forms);
enzyme studies (leukocytes, fibroblasts)
Farber disease (lipogranulomatosis, ceramidosis)

Enzyme: Ceramidase
Clinical: Hoarseness, skin nodules, painful contractures, corneal clouding,
neurodegeneration
Manif.: Infancy, fatal in 1–4 yrs; also juvenile forms
Bioch.: Ubiquitous ceramide storage
Diagn.: Biopsy (skin nodules): Ultrastructure; enzyme studies (fibroblasts)
Multiple sulphatase deficiency (mucosulphatidosis)

Protein: Sulphatase-modifying factor 1 = C-alpha-formylglycine generating enzyme
Clinical: Combined features of mucopolysaccharidosis (MPS II, III, IV & VI),
metachromatic leukodystrophy and ichthyosis due to steroid sulphatase
deficiency. Prominent proptosis.
Manif.: Infancy, fatal in 1–4 yrs
Bioch.: ' GAG (urine); GAG electrophoresis
Diagn.: Enzyme studies (leukocytes, fibroblasts). Deficiencies of several sulphatases,
including iduronate sulphatase, heparan sulphatase, arylsulphatase A & B and
steroid sulphatase
Mucolipidoses
The mucolipidoses (ML) combine clinical features of the mucopolysaccharidoses and

sphingolipidoses; the typical ML (types II, III) are associated with deficiency of several
lysosomal enzymes. Mucolipidosis type I has been used as a term for sialidosis (see
above).
Mucolipidoses II (I-cell disease) and III (pseudo-Hurler dystrophy)

Enzyme: N-acetylglucosamyl phosphotransferase (post-translational modification of
lysosomal enzymes in the Golgi apparatus for transport into lysosomes)
Clinical: ML II resembles Hurler disease with very early onset and severe course;
ML III is milder
Diagn.: Enzyme studies (serum, plasma, fibroblasts)
Mucolipidosis IV
Enzyme: Mucolipidin 1 (calcium channel protein, probably important for endocytosis)
Clinical: Progressive psychomotor retardation, corneal clouding
Diagn.: Gastrin elevated in almost all patients examined (may be useful screening
test); ubiquitous vacuolar and avacuolar storage of gangliosides and lipo-
pigment-like bodies; mutation analysis
Lipid storage disorders
Lipid storage disorders resemble the sphingolipidoses in their clinical features but are
characterised by storage of other lipid compounds. The neuronal ceroid lipofuscinoses
(e.g. Batten disease; see page 123) also belong to the group of lipid storage disorders.
Niemann-Pick disease type II (= type C, D)

Bioch.: Disorder of lysosomal cholesterol export; secondary storage of sphingomyelin
Clinical: Similar to type A (see page 119), plus hepatopathy, splenomegaly, severe
neonatal jaundice, ataxia, dystonia, vertical ophthalmoplegia, cataplexy
Manif.: Acute forms: Onset in the first few months, fatal within 2 yrs; also milder
forms
Diagn.: Cherry-red spot (50%), “Niemann-Pick cells” in bone marrow but normal-(&)
sphingomyelinase activity; cholesterol studies (fibroblasts)
Wolman disease
Enzyme: Acid lipase (function: e.g. cleavage of cholesterol esters from LDL, page 131)
Bioch.: Lysosomal storage of cholesterol esters and triglycerides
Clinical: Diarrhoea, vomiting, steatorrhoea, failure to thrive, abdominal distension,
hepatosplenomegaly, later anaemia, psychomotor retardation; typical adrenal
enlargement and calcifications
Manif.: First weeks, usually fatal in infancy
Var.: Mild enzyme defects with severe atherosclerosis in adults
Diagn.: ' Cholesterol (serum); enzyme studies (leukocytes)
Therapy: HMG-CoA reductase inhibitor for the treatment of atherosclerosis
Lysosomal transport defects
This group of disorders is characterised by failure to transport certain compounds across

the lysosomal membrane and also includes the cblF defect in cobalamin metabolism
(deficient lysosomal cobalamin release, see page 78).
Cystinosis
Clinical: Infantile: Nephropathy (tubulopathy, electrolyte disturbances) % renal failure;
endocrine disturbances, small stature; sometimes hepatosplenomegaly,
myopathy; corneal crystals (photophobia); later progressive central nervous
symptoms (adulthood);
juvenile: Nephropathy;
adult: Benign; corneal crystals
Diagn.: Cystine content of leukocytes
Therapy: Symptomatic (Fanconi syndrome), cysteamine (10–)50 mg/kg/day, cysteamine
eye drops
Progn.: Good response to early treatment but late complications frequent
Sialic acid storage disease (Salla disease)

Clinical: Hypotonia, ataxia, mental and growth retardation, spasticity, epilepsy
Manif.: Salla disease: Infantile onset, rel. long life-span, relatively common in
Finland;
Infantile sialic acid storage disease, ISSD: fatal in infancy
Diagn.: Free sialic acid (N-acetylneuraminic acid) in urine (thin-layer chromatography
or specific assay)
Neuronal ceroid lipofuscinoses
Ceroid lipofuscinoses are among the most common neurometabolic disorders but may be
difficult to diagnose.
Clinical: Behavioural changes, poor co-ordination, poor speech, gradual loss of
acquired skills, (myoclonic) epilepsy, progressive blindness (retinopathy, optic
atrophy), nystagmus, extrapyramidal signs % decerebration
Bioch.: Storage of autofluorescent lipid pigments or ceroid; accumulation of
sphingolipid activator proteins A and C (infantile forms) or subunit C of the
mitochondrial ATP synthase (other forms)
Diagn.: (Electron) microscopy (skin biopsy, lymphocytes): Distinct storage patterns.
Juvenile form/Batten disease: vacuolated lymphocytes often found by light
microscopy (electron microscopy may be necessary in the other forms);
enzyme studies are possible for some forms.
Infantile form (Santavuori-Haltia disease, CLN1)

Enzyme: Palmitoyl protein thioesterase
Clinical: Onset in infancy with regression, visual loss, epilepsy and microcephaly;
rapidly progessive, fatal within first decade.
Populat.: Finland
Diagn.: Vacuoles in lymphocytes or skin by (electron) microscopy; enzyme studies
(leukocytes, fibroblasts)
Late infantile form (CLN2, CLN5, CLN6, CLN7)

Protein: Pepstatin-insensitive peptidase (CLN2, Jansky-Bielschowsky disease);
unknown membrane proteins (CLN5, CLN6, CLN7)
Clinical: Onset at 2–4 yrs with seizures and progressive ataxia, regression, retinitis
pigmentosa. Death in childhood.
Populat.: Finland (CLN5), Roma/Mediterraneans (CLN6), Turkey (CLN 7)
Diagn.: Vacuoles in lymphocytes or skin by (electron) microscopy; enzyme studies
(CLN2: leukocytes, fibroblasts)
Juvenile form (Batten disease, Vogt-Spielmeyer disease, CLN3)

Protein: Unknown membrane protein
Clinical: Onset at pre-school age or later with retinitis pigmentosa, then slow
regression, mild epilepsy, behavioural disturbances, hallucinations, disturbed
sleep patterns, Parkinson disease-like rigor
Adult form (Kufs disease, CLN4)

Protein: probably heterogeneous
Clinical: Regression, (myoclonic) epilepsy, ataxia, pyramidal and/or extrapyramidal
symptoms. Broad variation in age of onset and clinical features
Diagn.: Characteristic vacuoles in biopsies
Peroxisomal metabolism
Biochemistry
Important peroxisomal functions include beta-oxidation of very long-chain fatty acids
and related substances, alpha-oxidation of 3-methyl fatty acids (e.g. phytanic acid) and
biosynthesis of etherlipids (special phospholipids that occur mainly in the CNS, heart
and skeletal muscle, e.g. plasmalogens), isoprenoids, cholesterol and bile acids. Many
oxygen-dependent reactions take place in the peroxisomes to protect the cell against
oxygen radicals; the produced H2O2 is metabolised by a catalase. Various peroxins
encoded by PEX genes have been identified that are required for peroxisome bio-
genesis and transmembrane transport. Peroxisomal proteins contain one of at least two
different targeting signals (PTS1 and 2) for peroxisomal import.
Clinical features
$ Neurological abnormalities – encephalopathy, hypotonia, seizures, deafness, etc.
$ Skeletal abnormalities, in particular short proximal limbs, calcific stippling
$ Ocular abnormalities – retinopathy, cataract, blindness, etc.
$ Dysmorphic features, in particular craniofacial abnormalities (severe forms)
$ Hepatointestinal dysfunction – neonatal hepatitis, hepatomegaly, cholestasis,
cirrhosis, etc. (severe forms)
Investigations
$ Routine: N–& cholesterol, n–' bilirubin, abnormal liver function tests
$ Very long-chain fatty acids (VLCFA, serum): ' C26, etc. – indicative of deficient
peroxisomal beta-oxidation, as found in the majority of known peroxisomal disorders
$ Plasmalogens (erythrocytes): Reduced in disorders affecting etherlipid biosynthesis
$ Phytanic acid (serum): Increased in disorders of peroxisome biogenesis and Refsum
disease (conversion to pristanic acid via phytanoyl-CoA hydroxylase; dietary origin,
therefore always low = “normal” in neonates)
$ Pristanic acid (serum): Increased in disorders affecting peroxisomal .-oxidation.
Isolated elevation indicates Į-methyl-acyl-CoA racemase deficiency.
$ Bile acid intermediates (serum, urine): Increased intermediary products; see also page
130
$ Enzyme studies, mutation analyses
VLCFA Plasma- Phytanic Pristanic Bile

logens acid acid acids
Disorders of peroxisomal Ĺ Ļ-N Ĺ-N Ĺ-N Ĺ-N
biogenesis and beta-oxidation
Rhizomelic chondrodysplasia N Ļ N-Ĺ Ļ-N N
punctata
X-linked adrenoleukodystrophy Ĺ N N N N
Refsum disease N N Ĺ Ļ N
Į-Methyl-acyl-CoA racemase N N (Ĺ) Ĺ Ĺ
deficiency
Peroxisomal metabolism 125
Disorders of peroxisome biogenesis

Defective peroxisome assembly resulting in the deficiency of various enzymes
Clinical: $ Neonatal period: Severe hypotonia, areactivity, seizures, ocular abnormalities
(cataract), liver dysfunction (severe neonatal jaundice, cholestasis,
' conj. bilirubin), dysmorphic and skeletal abnormalities, failure to thrive
$ Infancy: Retinopathy % blindness, sensory neural deafness, hepatopathy
(jaundice, hepatomegaly, portal hypertension), failure to thrive,
gastrointestinal symptoms, dysmorphic features
$ Childhood: Failure to thrive, osteoporosis, progressive psychomotor retar-
dation, neurological symptoms, blindness, deafness, dysmorphic features
Variants: Zellweger syndrome: Severe form, fatal within a few months
Neonatal adrenoleukodystrophy: Somewhat slower progression
Infantile Refsum disease: Mild variant: Onset in (early) childhood
Diagn.: Deficiencies in multiple (or all) peroxisomal enzymes
Disorders of peroxisomal beta-oxidation

Clinical: Similar to disorders of peroxisome biogenesis (“pseudo-Zellweger syndrome”,
“pseudoneonatal adrenoleukodystrophy”)
Enzymes: Acyl-CoA oxidase, bifunctional protein
Diagn.: ' VLCFA; ('1)specific bile acids; normal plasmalogens
Rhizomelic chondrodysplasia punctata

Clinical: Proximal shortening of the limbs, facial dysmorphy, small stature, micro-
cephaly, contractures, spasticity, mental retardation, cataracts, ichthyosis
Bioch.: Deficient peroxisomal import of certain proteins (receptor of peroxisomal
target signal 2, PTS2) or deficiency of single enzymes involved in
plasmalogen biosynthesis (dihydroxyacetonephosphate acyltransferase,
alkyldihydroxyacetonephosphate synthase – imported via PTS2)
Diagn.: & Plasmalogens; ' phytanic acid, & pristanic acid (normal in single enzyme
deficiencies),
X-ray: Stippling of the epiphyses
Therapy: Phytanic acid restriction may be beneficial in some cases
X-linked adrenoleukodystrophy (ALD)

Clinical: Boys (usually age 4–10): Behavioural disturbances, intellectual regression,
adrenal insufficiency, leukodystrophy % decerebration within 2–4 yrs
Young men, adult heterozygous women: Adrenomyeloneuropathy (AMN) –
spastic paraparesis (legs), sphincter problems, impotence, mixed demyelinating
and axonal peripheral neuropathy, adrenal insufficiency
Addison disease (may be the only manifestation)
Bioch.: Deficient ALD protein (ATP-binding membrane transporter for lignoceroyl-
[very long-chain acyl-]CoA synthetase) % deficient .-oxidation of VLCFA
Diagn.: ' VLCFA (plasma)
Therapy: Early bone marrow transplantation; “Lorenzo’s oil” (glyceryl trioleate +
glyceryl trierucate 4:1) does not improve long-term outcome.
Docosahexaenoic acid (DHA) may be of some benefit.
Refsum disease
Clinical: Retinitis pigmentosa, polyneuropathy, cerebellar ataxia; deafness, anosmia,
ichthyosis, skeletal and cardiac symptoms; normal intelligence
Manif.: School age
Enzyme: Phytanoyl-CoA hydroxylase (imported via PTS2, see above)
Diagn.: ' Phytanic acid, & pristanic acid; ' CSF protein concentration
Therapy: Diet (phytanic acid-restricted); plasmapheresis
Į-Methyl-acyl-CoA racemase
Clinical: Diarrhoea, liver disease, retinitis pigmentosa, polyneuropathy, epilepsy
Manif.: Young adults
Diagn.: ' Specific bile acids (bile, plasma, urine), ' pristanic acid, ('1 phytanic acid
Therapy: Substitution of bile acids
Other peroxisomal enzyme defects

$ Acatalasaemia (Catalase deficiency) % chronic mouth ulcers
$ Primary hyperoxaluria type I % nephrolithiasis, nephrocalcinosis
Differential diagnosis of chondrodysplasia punctata (CDP)

Clinical: Small stature (usually prenatal onset), (asymmetric) rhizomelic shortening of
the limbs, ichthyosis, atrophodermia, cataracts, psychomotor retardation
Histol.: Irregular stippled calcifications of the dystrophic epiphyseal cartilage
Inheritance Type Clinical Enzyme/protein

Aut. recessive Rhizomelic Severe Peroxisomal target signal 2 (PTS2);
CDP single enzymes of plasmalogen biosynthesis
X-linked dom. Conradi- Sterol !8-isomerase etc., see page 128
Hünermann
X-linked rec. Conradi- Arylsulphatase E
Hünermann
Aut. dominant Variable Unknown; few recent reports
Sterol metabolism 127
Sterol metabolism
Disorders of sterol biosynthesis
Sterol synthesis defects present clinically as multi-system disorders with dysmorphic

features and variable skeletal dysplasies; they should also be considered in cases of
otherwise unexplained recurrent abortions and fetal dysmorphy. The biochemical
diagnosis is not always straight-forward: Serum cholesterol is usually normal in all
disorders except (sometimes) Smith-Lemli-Opitz syndrome (SLOS) and even specific
sterol analysis may yield normal results. In these instances the diagnosis can be reached
by mutation analysis or functional studies (fibroblasts cultured in sterol-free media).
Pathogenesis appears to be related mostly to prenatal development in all disorders except
mevalonate kinase deficiency and SLOS. Treatment with cholesterol is rarely warranted
except in patients with hypocholesterolemia and SLOS.
Biochemistry
3 x Acetyl-CoA HMG-CoA
Thiolase
Cytosolic HMG-CoA reductase
HMG-CoA
synthase Mevalonate
Mevalonate kinase
Isopentenyl-tRNA
Geranylgeranylated and
Dimethylallyl-PP Isopentenyl-PP
farnesylated proteins
Haem-a
Dolichol-PP
Lanosterol Ubiquinone
"24-Reductase
14!-Demethylase (Desmosterol 14!-Demethylase
reductase)
"14-Reductase
4-Demethylase complex
8-Dehydro-
cholesterol "8,"7-Isomerase
"5-Desaturase
Cell membrane
7-Dehydrocholesterol Steroid hormones
"7-Reductase D-vitamins
Bile acids
"24-Reductase
Desmosterol Cholesterol Hedgehog pathway
The first step of cholesterol biosynthesis is the cytosolic condensation of three acetyl-
CoA to 3-hydroxy-3-methylglutaryl-(HMG-)CoA, which is then converted via meva-
lonic acid to activated isoprenoids. Further modification and condensation produces
lanosterol, the first sterol and precursor of cholesterol.
Mevalonic aciduria, hyper-IgD syndrome

Clinical: Mevalonic aciduria: Dysmorphy, dystrophy, progressive ataxia due to
cerebellar atrophy, psychomotor retardation, retinitis pigmentosa, recurrent
crises with fever, skin rash, lymphadenopathy, hepatosplenomegaly
Hyper-IgD syndrome: Recurrent febrile attacks
Enzyme: Mevalonate kinase
Bioch.: Disorder of the biosynthesis of cholesterol and isoprenoids
Diagn.: OA (urine): (') Mevalonic acid, mevalonolactone (typically > 500 mmol/mol
creat. in mevalonic aciduria, < 100 mmol/mol creat. in hyper-IgD syndrome);
')leukotrienes, prostanoids (urine); serum: ')CK,)IgD, transaminases,
n–& cholesterol, bile acids, ubiquinone
Therapy: Intermittent steroids or leukotriene receptor inhibitors during acute phase;
substitution with ubiquinone, vitamins E and C
Desmosterolosis
Clinical: Facial dysmorphy, cleft palate, multiple malformations, ambiguous genitalia,
short limbs, osteosclerosis, psychomotor retardation
Enzyme: 3&-Hydroxysterol !24-reductase (desmosterol reductase)
Bioch.: Disorder of the biosynthesis of cholesterol but not of isoprenoids
Diagn.: Sterols (plasma, fibroblast cultures): ' Desmosterol
Antley-Bixler syndrome (Lanosterolosis)

Clinical: Multiple anomaly syndrome with limb anomalies, craniofacial dysmorphisms
and, in some, ambiguous genitalia
Enzyme: POR (flavoprotein that donates electrons to all P450 oxidoreductases, e.g.
3&-hydroxysterol 14&-demethylase (CYP51A1)
Diagn.: Sterols (plasma, fibroblast cultures): ' Lanosterol, dihydrolanosterol
Greenberg dysplasia, Pelger-Huët anomaly

Clinical: Greenberg dysplasia: Severe chondrodysplasia punctata, non-immune
hydrops fetalis, lethal prenatally
Pelger-Huët anomaly: Psychomotor retardation, epilepsy (heterozygous
mutations), additional skeletal abnormalities when homozygous for specific
mutations
Enzyme: 3&-Hydroxysterol !14-reductase (lamin B receptor; LBR gene)
Diagn.: Greenberg dysplasia: Sterols (plasma, fibroblast cultures):)')Cholesta-8,14-
diene-3-betaol; Pelger-Huët anomaly: abnormally shaped blood granulocytes
CHILD syndrome (X-linked dominant)

Clinical: Unilateral ichthyotic skin lesions with a sharp demarcation at the midline of
the trunk, stippled epiphyses on the affected side, limb defects; lethal in males
Enzyme: 3&-Hydroxysterol 4-demethylase complex
Diagn.: Sterols (plasma, fibroblast cultures): ')4-Methylsterols
Therapy: Experimental: cholesterol 50–150 mg/kg in patients with hypocholesterolemia
or active skin disease
Sterol metabolism 129
Chondrodysplasia punctata Conradi-Hünermann (X-linked dominant)

Clinical: Rhizomelic short stature with asymmetric shortening of proximal limbs,
stippled epiphyses, cataracts, ichthyosis, psychomotor retardation; lethal in
males
Enzyme: 3&-Hydroxysterol 28,27-isomerase )
Diagn.: Sterols (plasma, fibroblast cultures): ' 8-Dehydrocholesterol, 8(9)-cholestenol
DD: See page 126
Therapy: Experimental: cholesterol 50–150 mg/kg in patients with hypocholesterolemia
or active skin disease
Lathosterolosis
Clinical: Severe malformations, overlapping the spectrum of Smith-Lemli-Opitz
syndrome; lipid storage
Enzyme: 3&-Hydroxysterol !5-desaturase
Diagn.: Sterols (plasma, fibroblast cultures): ' Lathosterol
Therapy: Lipid storage might be aggravated by supplemental cholesterol
Smith-Lemli-Opitz syndrome
Clinical: Malformations: Craniofacial dysmorphy (microcephaly, micrognathia,
anteverted nostrils, ptosis); syndactyly of 2nd and 3rd toes (almost obligatory);
renal, cardiac, gastrointestinal and mid-line malformations including holopros-
encephaly, genital malformations in boys; (compensated) adrenal insufficiency
may decompensate during illnes; psychomotor retardation, behavioural
disturbances, feeding problems, failure to thrive;
very variable severity ranging from intra-uterine death to normal life span
Enzyme: 3&-Hydroxysterol 27-reductase
Bioch.: Defect of the last step of cholesterol biosynthesis
Diagn.: Sterols (plasma, fibroblast cultures): ')7-Dehydrocholesterol (7-DHC) and
8-DHC; n–& cholesterol; mutation studies
Therapy: Cholesterol 50–100 mg/kg, higher in infants; simvastatin 0.5–1 mg/kg in
2 doses may be useful in mildly affected patients. In an acute illness, when
enteral cholesterol supplementation cannot be continued, frozen plasma can be
given as an emergency source of LDL cholesterol.
Disorders of bile acid synthesis
Biochemistry
Bile acids are synthesised from cholesterol in the liver. The first reaction (7!-hydroxy-
lation) is rate-limiting; some steps involve peroxisomal .-oxidation. The two main bile
acids, cholic and chenodesoxycholic acids, are activated to CoA esters, conjugated
with either glycine or taurine to form bile salts and excreted into the bile. Bile acids are
essential for lipid resorption in the gut, they regulate hepatic cholesterol synthesis
(inhibition of HMG-CoA reductase) and are necessary for adequate bile production.
Bile acid synthesis defects with cholestasis and malabsorption

Clinical: Prolonged neonatal jaundice, steatorrhoea, treatment-resistant diarrhoea,
rickets, haemorrhage, sometimes hepatosplenomegaly, pruritus
Enzymes: $ 3&-Hydroxy-25-C27-sterol dehydrogenase (= PFIC type 4, see page 155)
4
$ 2 -3-Oxosterol 5&-reductase
$ Oxysterol 7'-hydroxylase
Diagn.: (n–)' Conjugated bilirubin, transaminases, AP, PTT; normal "GT;
n–& calcium, n–& cholesterol; & vit. E, D, K, A; ' specific bile acids (bile,
plasma, urine)
DD: Progressive familial intrahepatic cholestasis (PFIC), page 155
Therapy: Substitution of bile acids.
Progn.: Good except for oxysterol 7'-hydroxylase deficiency which may require liver
transplantation.
Cerebrotendinous xanthomatosis
Clinical: Self-limiting neonatal hepatitis; psychomotor retardation, treatment-resistant
diarrhoea, cataract (specific type), later xanthomas (from 2nd decade);
atherosclerosis, osteoporosis;
progressive ataxia % dementia
Enzyme: Sterol 27-hydroxylase
Bioch.: Accumulation of cholestanol (and cholesterol) particularly in the nervous
system
Diagn.: (') Cholestanol, n–' cholesterol (plasma); ' specific bile alcohols (urine)
Therapy: Substitution of bile acids, statins
Protein glycosylation 131
Protein glycosylation
Biochemistry
CDG Ib CDG Ia
Fru-6-P Man-6-P Man-1-P
Dolichol-P CDG Ik
Cytosol CDG Ii
CDG If
CDG Ie
CDG Id
CDG Il
ER CDG Ig
CDG Ic
CDG Ih
CDG IIb
CDG IIe
CDG IIa
Golgi CDG IId
Glucose
Galactose
Mannose
N-Acetylglucosamine CDG IIc
Sialic acid Fucose GDP-Fucose
Many enzymes, transport and membrane proteins, hormones etc. require glycosylation
to render them functional (glycoproteins). More than 30 enzymes are involved in the
formation of carbohydrate side chainsin the cytoplasma, endoplasmic reticulum (ER)
or Golgi apparatus. Glycoprotein breakdown takes place in the lysosomes.
Fru = Fructose, Man = Mannose
Congenital disorders of glycosylation (CDG)
This group of disorders (previously denoted carbohydrate-deficient glycoprotein

syndromes) is characterised by a disturbance of various physiological functions and a
broad spectrum of symptoms. The classification is based on pathophysiological
considerations: CDG type I comprises defects in the assembly of the dolichol-linked
glycan and its transfer to the protein (mostly in the endoplasmic reticulum) whereas CDG
type II refers to defects in the processing of the protein-bound glycans (mostly in the
Golgi apparatus). So far, the molecular basis has been elucidated for 16 defects (CDG-
Ia–Il and CDG-IIa–IId). By far the most common CDG type is type Ia (phosphomanno-
mutase deficiency).
Diagnosis
The diagnostic work-up should start with analysis of glycosylation patterns in
isoelectric focussing (IEF) of transferrin (see page 36). The IEF patterns are divided
into type 1, (elevated disialotransferrin and asialotransferrin bands together with a
decrease in tetrasialotransferrin) and type 2 (trisialotransferrin and monosialotrans-
ferrin bands also elevated); these types also correspond to the CDG types. Secondary
glycosylation disorders may be caused by chronic alcoholism, classical galactosaemia
or fructose intolerance (deficient mannose-6-phosphate synthesis).
Treatment
Treatment is symptomatic in most CDG types. Mannose administration is a successful
therapy for CDG-Ib and fucose has been used to improve the clinical picture of CDG-
IIc patients.
CDG type Ia
Most common CDG, ~ 80% of patients diagnosed so far. The disease may present in
infancy with severe infections, liver/heart failure, bleeding tendency or thromboses; older
children usually display non-progressive mental retardation and neurological symptoms.
The diagnosis is confirmed by enzyme studies (see table), treatment is symptomatic.
General: Variable dysmorphy, inverted nipples, unusual fat pads,
failure to thrive, diarrhoea, vomiting, thrombo-embolic events
Behaviour: Often extroverted, happy character; stereotypic behaviour
Neurology: Psychomotor retardation (IQ 40–60), hypotonia, deafness, epilepsy,
cerebellar atrophy, dysmyelinisation, haemorrhagic cerebral infarcts,
neuropathy, & nerve conduction velocity
Eye: Strabismus, retinitis pigmentosa, cataracts
Heart: Pericardial effusion, cardiomyopathy, heart malformation
Liver: Hepatomegaly, fibrosis; histology: Inclusion bodies
Kidney: Proteinuria, nephrotic syndrome
Skeletal: Kyphoscoliosis from school age, contractures, wheel-chair dependency
Endocrine: Hypogonadism, absent puberty (females), hypoglycaemia
Haemostasis: Abnormal coagulation studies, haemorrhages or embolic events
Clin. Chemistry: & various serum proteins (AT III, factor XI, protein C, protein S)
Legend to table on opposite page

Shown are the main clinical features, the deficient enzyme and its cellular localisation,
the IEF type pattern as well as the cell types used for enzymatic confirmation of the
diagnosis.
Localisat. = localisation: C = cytosol; ER = endoplasmic reticulum; G = Golgi apparatus;
Confirm. = cells for confirmation of diagnosis: L = leukocytes; F = fibroblasts;
n = normal findings in transferrin IEF
Protein glycosylation 133
Known CDG types
CDG Enzyme Main clinical features
Localisat.
Confirm.
IEF type
Type
Ia Phosphomanno- C 1 L Psychomotor retardation, dysmorphy,

mutase or inverted nipples, cerebellar atrophy,
F coagulation abnormalities (see above)
Ib Phosphomannose C 1 L Gastrointestinal symptoms, hepato-
isomerase or megaly, congenital fibrosis of the liver;
F no psychomotor retardation; coagulation
abnormalities, therapy: Mannose
Ic '1,3-Glucosyl ER 1 F Hepatogastrointestinal symptoms,
transferase psychomotor retardation
Id 1,3-Mannosyl ER 1 F Psychomotor retardation, seizures,
transferase microcephaly
Ie Dolichol-P-mannose ER 1 F Psychomotor retardation, seizures, axial
synthase I hypotonia, dysmorphy
If Dolichol-P-mannose ER 1 F Psychomotor retardation, seizures, skin
utilisation disease
Ig '1,6-Mannosyl ER 1 F Psychomotor retardation, hypotonia,
transferase dysmorphy
Ih '3-Glucosyl ER 1 F Gastrointestinal symptoms,
transferase hepatomegaly, coagulation abnormalities
Ii '1,3-Mannosyl ER 1 F Ophthalmological abnormalities, seizures,
transferase retardation, coagulation abnormalities
Ik "1,4-Mannosyl ER 1 F Recurrent seizures, micropcephaly,
transferase coagulation abnormalities
Il '1,2-Mannosyl ER 1 F Developmental delay, hypotonia, seizures,
transferase hepatomegaly
IIa N-Acetyl- G 2 F Severe psychomotor retardation but no
glucosaminyl neuropathy or cerebral hypoplasia;
transferase coagulation abnormalities
IIb Glucosidase I ER n F Hepatomegaly, hypoventilation, feeding
problems, seizures
IIc GDP-fucose G n F Dysmorphy, psychomotor retardation,
transporter severe infections
IId "1,4-Galactosyl G 2 F Macrocephaly, hydrocephalus, hypotonia,
transferase coagulation abnormalities, myopathy
IIe COG-7 = subunit of G 2 F Dysmorphy, skeletal dysplasia, hypotonia,
COG complex in hepatosplenomegaly, jaundice, epilepsy,
Golgi-trafficking death in infancy
Legend: See previous page
Lipoprotein metabolism
Biochemistry
Lipoproteins are the lipid transport vehicles of the blood. The core of these particles
contains hydrophobic molecules including triglycerides and cholesterolesters whilst the
surface is composed of hydrophilic, charged molecules such as phospholipids and
cholesterol. Apolipoproteins which are attached to the particles are required for struc-
tural integrity (ApoB-100, ApoB-48, ApoA-I) and serve as ligands (ApoB-100, ApoE,
ApoA-I) or cofactors (ApoC-II, ApoA-I, ApoA-IV) for specific enzymes. Lipoproteins
are classified according to density into high-density lipoproteins (HDL), intermediate
(IDL), low (LDL) and very low-density lipoproteins (VLDL) as well as chylomicrons.
Chylomicrons and VLDL represent the triglyceride-rich lipoproteins and are

assembled in the Golgi apparatus of duodenal mucosa and hepatocytes, respectively.
Chylomicrons serve as transport vehicles of triglycerides absorbed in the gut, are
synthesised in large quantities after meals and enter the blood stream via lymphatic
vessels. VLDL are synthesised by the liver and also supply the peripheral cells with
triglycerides and (particularly after conversion into LDL) cholesterol. ApoC-II plays an
important role in chylomicron and VLDL breakdown as the cofactor of
lipoproteinlipase (a glycoprotein attached to the endothelium) which cleaves
triglycerides into glycerol and fatty acids for further metabolism in the cell. The
remnants of the chylomicrons are taken up by the liver (via the ApoE receptor) and
metabolised. VLDL changes into IDL and after removal of further lipids finally turns
into the cholesterol-rich LDL particles. If these are not required in the periphery they
are taken up again by the liver via the LDL receptor.
LDL is found in several different subfractions (LDL1–LDL6); LDL 6 is described as a

small, dense and highly atherogenic particle. LDL binds via ApoB-100 to the LDL
receptor, is taken up by endocytosis and broken down in the lysosome, mainly by acid
lipase (see page 121). Cholesterol ist released, inhibits the activity of HMG-CoA
synthase (see page 127) and is stored via acyl-CoA cholesterol acyltransferase
(ACAT) in the lipid droplets of the cell.
HDL is also found in different subfractions (HDL1–3). It is generated mainly by

chylomicron metabolism and interaction with VLDL. Via ApoA-I (the major protein
component) and ApoA-IV, HDL activates lecithin:cholesterol acyltransferase
(LCAT), inducing enrichment with cholesterol esters. These may be exchanged for
triglycerides of other lipoproteins via the exchange protein CETP. By this mechanism,
most of the HDL cholesterol is metabolised via the LDL pathway. HDL is also taken
up directly (mainly via ApoAI) and broken down by the liver. HDL thereby serves as a
transport vehicle for “reverse” cholesterol transport from peripheral cells back to the
liver and has a vasoprotective effect.
Lipoprotein metabolism 135
Lipoprotein Apolipoprotein (Apo) Function

Chylomicrons A-I, A-IV, C-I, C-II, Transport of exogenous triglycerides, fat
C-III, E, B-48 soluble vitamins and drugs
VLDL CI-III, E, B-100 Transport of endogenous triglycerides
IDL CII, E, B-100 Product of VLDL triglyceride removal
LDL B-100 Product of IDL triglyceride removal;
cholesterol transport to extrahepatic tissue;
regulation of cholesterol biosynthesis
HDL A-I, A-II, A-IV, Mainly modification of other lipoproteins,
C-I, C-III, D, E cholesterol transport to the liver
Lipoprotein (a) B-100, Apo (a) Uncertain, possibly for vascular repair; risk
factor for atherosclerosis
Hypercholesterolaemias
Familial hypercholesterolaemia (FH)

Clinical: Premature atherosclerosis, familial vascular disease (infarctions), xanthomas,
xanthelasms, thickened tendons (e.g. Achilles tendon), arcus corneae;
homozygous: Severe atherosclerosis from early childhood; DD sitosterolaemia
Protein: LDL receptor (LDLR)
Genetics: Inheritance: Autosomal co-dominant, incidence: Heterozygous ~ 1:500
Diagn.: ' Cholesterol (heterozygous ~ 300 mg/dl, homozygous > 600 mg/dl),
normal triglycerides, & HDL; mutation analysis; family history (cholesterol
> 260 mg/dl + cardiovascular disorder in parents)
Procedure: Total cholesterol > 220 mg/dl (5.7 mmol/l), normal HDL (> 35 mg/dl):
$ LDL-cholesterol 130–150 mg/dl: Check again within 2 yrs
$ LDL-cholesterol > 150 mg/dl (3.9 mmol/l): Restrict cholesterol in the diet
$ LDL-cholesterol > 190 mg/dl (4.9 mmol/l) despite diet for 6–12 mths or
> 160 mg/dl (4.2 mmol/l) + positive family history: Consider drug therapy
$ LDL-cholesterol > 250 mg/dl (6.5 mmol/l): Transfer to metabolic centre
Therapy: Diet: (cholesterol < 300 mg/day, modify fat composition, total fat < ! of
energy); drugs: Anion exchangers (cholestyramine – increase gradually, final
dose 0.2–0.4 g/kg in 2–3 doses), consider sitosterin (1–6 g/day), fibrates,
HMG-CoA reductase inhibitors (= statins);
homozygous patients: Cholesterol removal via LDL apharesis (weekly to
fortnightly); consider liver transplantation; gene therapy not yet successful
Follow-up: 3–6-mthly during diet therapy
Familial ApoB-100 deficiency (FDB)

Clinical: Same as in LDLR deficiency; homozygosity: Cholesterol level and cardio-
vascular risk as in heterozygotes (ApoB function partly replaced by ApoE)
Genetics: Inheritance: Autosomal co-dominant; incidence: Heterozygous ~ 1:700;
Missense mutations in the receptor binding region, e.g. R3500Q
Therapy: Same as in LDL receptor deficiency
Sitosterolaemia (= phytosterolaemia)
Clinical: Xanthomas, premature atherosclerosis (differential diagnosis); occasionally
haemolysis
Bioch.: ' Intestinal absorption and & biliary excretion of fish/plant sterols
Genetics: Autosomal recessive
Diagn.: n–'' Cholesterol; ' phytosterols/sitosterols (serum, GC-MS)
Therapy: Effective diet therapy (& plant oils, etc.) and anion exchange resins
Other hypercholesterolaemias
$ Wolman disease: Lysosomal cholesterol-ester storage disease, see page 121
$ Hyperlipoprotein(a) disease
$ Hyperbetalipoproteinaemia
$ Polygenic hypercholesterolaemia
$ Secondary hypercholesterolaemia in hypothyroidism, renal disease, Cushing
syndrome, anorexia nervosa, acromegaly or increased STH secretion
Mixed hyperlipidaemias
Type III hyperlipidaemia (familial dysbetalipoproteinaemia)

Clinical: Xanthomas, xanthelasms, orange discolouration of hand creases; athero-
sclerosis
Bioch.: ApoE variants % deficient IDL/remnant uptake in the liver
Genetics: Common: Homozygosity for ApoE2 variant (autosomal recessive);
other mutations in the receptor binding domain (autosomal dominant)
Incidence: 1:5 000
Diagn.: ' Cholesterol and triglycerides, typical pattern in lipid electrophoresis
Therapy: Treat other risk factors (e.g. diabetes mellitus); diet; lipid lowering drugs
Familial combined hyperlipoproteinaemia

Clinical: Milder than LDL receptor deficiency
Bioch.: Uncertain; overproduction of VLDL
Genetics: Heterogeneous; incidence up to 1:300
Diagn.: ' Cholesterol and triglycerides; family history, alternating lipid phenotype
within the family and over time; “chameleon of lipidology”
Therapy: Effective diet therapy (& rapidly absorbed carbohydrates), statins
Other mixed hyperlipidaemias

$ Hepatic lipase deficiency: Similar to ApoE variants
Lipoprotein metabolism 137
Hypertriglyceridaemias
Familial chylomicronaemia (Frederickson HLP I or V)

Clinical: Abdominal complaints, failure to thrive, recurrent, sometimes fatal
pancreatitis, hepatosplenomegaly, eruptive xanthomas; no increased risk of
atherosclerosis; often asymptomatic
Enzyme: Lipoproteinlipase (LPL) or ApoCII
Genetics: Autosomal recessive; symptomatic carriers with additional risk factors
Bioch.: Disorder of triglyceride breakdown from chylomicrons and VLDL
Diagn.: '' Triglycerides (chylomicrons, VLDL)
DD: Drugs, alcohol, renal disease
Therapy: Restrict fat as much as possible, avoid aggravating hormones (steroids,
oestrogens); consider supplementation of medium-chain triglycerides (MCT).
acute: Lipid apheresis; in ApoCII deficiency: Supplement ApoCII (in FFP)
Familial hypertriglyceridaemia
Clinical: Mostly asymptomatic; as “metabolic syndrome” associated with obesity,
disturbed glucose tolerance, ' uric acid, hypertension
Bioch.: Aetiology unclear, probably polygenic; occasionally mutations in LPL gene
Diagn.: ' Triglycerides (VLDL, chylomicrons); sometimes periph. insulin resistance
DD: Diabetes mellitus, Cushing syndrome, hypothyroidism, renal disease, etc.
Therapy: Symptomatic; diet, & rapidly absorbed carbohydrates, consider drugs (fibrates,
nicotinamide), fish oils, weight loss, regular exercise
Disorders of HDL metabolism
Hypoalphalipoproteinaemia (& HDL, & ApoAI), often familial, is an important risk factor
of premature atherosclerosis. The aetiology is freqeuntly unclear; secondary causes
include hypertriglyceridaemia, liver failure, intestinal disorders, acute inflammation or
certain drugs (e.g. steroids). Therapy is symptomatic through avoidance of other risk
factors of atherosclerosis.
Apolipoprotein AI deficiency
Clinical: Early atherosclerosis, xanthomas, corneal clouding; occasionally amyloidosis
Genetics: Various mutations in the ApoAI gene, different severity; sometimes associated
with familial amyloidosis
Diagn.: & HDL, & ApoAI,
Therapy: Avoid risk factors of atherosclerosis
Tangier disease
Clinical: Polyneuropathy (weakness, paraesthesias, autonomic dysregulation, ptosis,
etc.); hyperplastic orange tonsils, orange discolouration of intestinal mucosa;
hepatosplenomegaly, corneal clouding; autosomal recessive inheritance
Bioch.: Generation of foam cells possibly due to disturbed intracellular transport of
cholesterol esters in macrophages
Diagn.: & HDL, & ApoAI, ' triglycerides, n–& cholesterol
Fish-eye disease
Clinical: Corneal clouding (isolated in classical fish-eye disease),
nephropathy % renal failure, hypochromic anaemia
Enzyme: Lecithin:cholesterol acyltransferase (LCAT)
Diagn.: & HDL, & ApoAI, ' triglycerides, free/total cholesterol > 0.7
Elevation of HDL
$ Familial hyperalphalipoproteinaemia: Cholesterol-ester transfer protein (CETP)
deficiency % cholesterol-esters remain in HDL. ' HDL; clinically asymptomatic
often increased life-span
$ Secondary: Exercise, alcohol, drugs (e.g. oestrogens)
Disorders with decreased LDL cholesterol and triglycerides
Familial abetalipoproteinaemia
Clinical: Fat malabsorption (steatorrhoea, vomiting, failure to thrive); vit. E/A
deficiencies (neuropathy, ataxia, cerebellar signs; retinopathy; myopathy),
Protein: Microsomal triglyceride transfer protein (MTTP)
Bioch.: Deficient triglyceride transport into endoplasmic reticulum % deficient
production of ApoB-containing lipoproteins; deficient transport capacity for
fat-soluble vitamins and drugs; erythrocyte dysfunction
Diagn.: && Cholesterol and triglycerides; lack of ApoB; blood smear: Acanthocytes
(DD see page 29); normal cholesterol, triglycerides & ApoB in the parents
Therapy: Vit. E 100 mg/kg/day; vit. A, K, D (i.m.); very low fat diet
Familial hypobetalipoproteinaemia
Clinical: Like MTTP deficiency, but milder
Protein: Apolipoprotein B
Genetics: Autosomal co-dominant
Diagn.: Like MTTP deficiency; parents & cholesterol, triglycerides, ApoB
Anderson disease
Clinical: Fat malabsorption, failure to thrive, vitamin deficiency
Bioch.: ? Disorder of chylomicron assembly in enterocytes
Diagn.: & Cholesterol, triglycerides, ApoAI, ApoB; fat droplets in enterocytes
Purine and pyrimidine metabolism 139
Purine and pyrimidine metabolism
Biochemistry: Purines Pyrimidines
Ribose-5-P Gln-NH3 HCO3-

DNA/RNA PRPS CPS2
biosynthesis
PRPP Carbamylphosphate
DNA RNA
SAICAR Orotate
dATP ATP ADSL UMPS
AICAR OMP
dADP ADP CDP UMPS
ADSL
AMP IMP GMP CMP UMP dTMP
AMPD1
UMPH UMPH UMPH
ADA
Adenosine Inosine Guanosine Cytidine Uridine Thymidine
APRT HPRT HPRT
NP NP TP
Adenine Hypoxanthine Guanine Uracil Thymine

XDH DPD DPD
Xanthine Dihydrouracil Dihydrothymine

DHP DHP
XDH
!-Ureidopropionate !-Ureidoisobutyrate
Urate
Ureidopropionase
!-Alanine !-Aminoisobutyrate
Purine biosynthesis involves a complex pathway resulting in inosine monophosphate

(IMP) which is converted into adenosine or guanosine monophosphate (AMP, GMP).
Purines are catabolised via hypoxanthine and xanthine to uric acid.
Pyrimidine biosynthesis starts with carbamylphosphate (synthesised by cytosolic
carbamylphosphate synthase II [CPS2] – for CPS1 see page 61) and, via orotic acid
(see also page 36), leads to uridine monophopsphate (UMP) and subsequently cytidine
or thymidine compounds. DNA and RNA biosynthesis is shown on the example of
AMP. For enzyme abbreviations see text.
Clinical features
$ Renal manifestations: Recurrent urinary tract infections, nephrolithiasis, renal failure
$ Neurological manifestations: Psychomotor retardation, epilepsy, spasticity, dystonia,
ataxia, autism, self-mutilation, deafness
$ Arthritis
$ Small stature
$ Muscle cramps and muscle wasting
$ Anaemia
$ Immunodeficiency with recurrent infections
Investigations
$ Uric acid in serum, total uric acid in 24-hr urine
$ Uric acid per creatinine in morning urine (mol/mol = 0.67 x mg/mg):
Uric acid Neonates 1st yr Age 2–5 Age 6–14 Adults

mol/mol creatinine 0.2–3 0.2–2 0.2–1.5 0.2–1 0.15–0.6
– Elevated: PRPS superactivity, Lesch-Nyhan syndrome, familial juvenile
hyperuricaemic nephropathy
– Decreased: NP deficiency, xanthinuria, nucleotidase hyperactivity
$ Urine crystals
$ Purines and pyrimidines in urine by HPLC (see page 37)
– 24-hr urine, alternatively morning urine (purine and pyrimidine excretion is
affected by the diet and may vary considerably during the day)
– Avoid methylxanthines (coffee, black tea, cocoa, liquorice) one day before and
during urine collection
– Exclude renal tract infection
– For the diagnosis of neurological disease: Freeze urine immediately, ship on dry
ice (unstable marker metabolites in adenylosuccinase deficiency)
Disorders of purine metabolism
Phosphoribosyl pyrophosphate synthetase (PRPS) superactivity

Clinical: Hyperuricaemia % nephrolithiasis, gout, sensorineural deafness
Manif.: Young men (in children: Deafness, psychomotor retardation, ataxia,
dysmorphy)
Bioch.: Overproduction of IMP; X-linked inheritance
Diagn.: ' Uric acid, ' hypoxanthine
Therapy: Diet (purine-restricted); alkalise urine, plentiful fluids; allopurinol (2–)10–20
mg/kg/day (beware of xanthine stones – monitor xanthine and oxypurinol )
Adenylosuccinate lyase (ADSL) deficiency

Clinical: Severe psychomotor retardation, epilepsy, autism, ataxia, sometimes growth
retardation
Manif.: Neonates, infants
Bioch.: Disorder of purine biosynthesis (IMP) and specifically AMP biosynthesis
Diagn.: ' Succinyladenosine, ' SAICA riboside; AA after acid hydrolysis: ' Asp, Gly
Myoadenylate deaminase (muscle AMP deaminase, AMPD1) deficiency

Clinical: Exercise: Rapid fatigue, muscle cramps
Manif.: From childhood (often few or no symptoms)
Diagn.: ' CK; ischaemia test (see page 52): Insuff. rise in NH3, normal rise in lactate
Therapy: Consider ribose 2–60 g/day
Adenosine deaminase (ADA) deficiency

Clinical: Severe combined immunodeficiency (SCID); diarrhoea, failure to thrive;
progressive neurological symptoms (spasticity, movement disorder)
Manif.: Neonatal (rarely up to school age)
Bioch.: Inhibition of ribonucleotide reductase by adenosine
Diagn.: Blood count: Lymphopenia; hypogammaglobulinaemia; ' Adenosine
Therapy: Bone marrow transplantation, enzyme replacement (expensive), gene therapy
Nucleoside phosphorylase (NP) deficiency

Clinical: Cellular immunodeficiency; immunohaemolytic anaemia, progressive
neurological symptoms (spasticity, movement disorder, retardation) more
frequent than in ADA deficiency
Manif.: 1–6 yrs, rarely later
Diagn.: & Uric acid, ' inosine, guanosine (deficient breakdown)
Therapy: Bone marrow transplantation
Xanthinuria
Clinical: Haematuria, nephrolithiasis (xanthine = radiolucent), renal failure,
arthropathy, myopathy, often asymptomatic (> 50% of homozygotes)
Manif.: From early childhood
Enzyme: Xanthine oxidase = xanthine dehydrogenase (XDH)
Var.: Molybdenum cofactor deficiency: Also sulphite oxidase defect (see page 77)
Diagn.: & Uric acid, '' xanthine, ' hypoxanthine
Therapy: Diet (purine-restricted), plentiful fluids, if residual activity: Allopurinol
Familial juvenile hyperuricaemic nephropathy

Clinical: Gout, early renal failure
Manifest.: From puberty
Bioch.: Cause unclear, possibly renal transport defect
Diagn.: Hyperuricaemia, & renal uric acid excretion; positive family history
Lesch-Nyhan syndrome
Clinical: Motor retardation, muscular hypotonia, dystonia, choreoathetosis, spasticity,
epilepsy, self-mutilation; uric acid stones (radiolucent) % renal failure; gout
Manif.: From 3–4 mths, progressive deterioration
Enzyme: Hypoxanthine:guanine phosphoribosyltransferase (HPRT) (X-linked)
Bioch.: Deficient regeneration of IMP (from hypoxanthine) and GMP (from guanine)
Var.: Mild forms: Gout, occasionally few neurological symptoms
Diagn.: '' Uric acid (morning urine: ' uric acid per creatinine), ' hypoxanthine
Therapy: Diet (purine-restricted), plentiful fluids, allopurinol; symptomatic
(neurological complications)
Adenine phosphoribosyltransferase (APRT) deficiency

Clinical: Nephrolithiasis (2,8-dihydroxyadenine) % renal failure
Manif.: All age groups (neonatal to old age) may be asymptomatic
Diagn.: ' Adenine, 2,8-dihydroxyadenine (adenine metabolite, produced by XDH)
Therapy: Diet (purine-restricted), plentiful fluids, allopurinol; do not alkalise urine
Disorders of pyrimidine metabolism
Hereditary orotic aciduria

Clinical: Megaloblastic anaemia, not responding to treatment % failure to thrive,
retardation
Manif.: Neonate, infant
Enzyme: Uridine-monophosphate synthase (UMPS)
Bioch.: Pyrimidine deficiency
Diagn.: '' Orotic acid
Therapy: Uridine (25–)100–150 mg/kg/day (monitor therapy: Urinary orotic acid)
Pyrimidine 5'-nucleotidase deficiency

Clinical: Chronic haemolytic anaemia (basophilic stippling)
Enzyme: Uridine monophosphate hydrolase (UMPH)
Diagn.: Erythrocyte analysis (' glutathione; nucleotide profile)
DD: Chronic lead intoxication (inhibitor of UMPH)
Progn.: Relatively good; transfusions rarely necessary
Dihydropyrimidine dehydrogenase (DPD) deficiency

Clinical: Frequently asymptomatic, sometimes mental retardation, epilepsy,
microcephaly, failure to thrive; severe (occasionally fatal) 5-fluorouracil
toxicity in asymptomatic patients and heterozygotes
Diagn.: ' Uracil, thymine (insufficient degradation)
Thymidine phosphorylase (TP) deficiency

Clinical: Mitochondrial encephalopathy with gastro-intestinal symptoms (MNGIE)
Bioch.: Mitochondrial DNA depletion syndrome (see page 92)
Diagn.: ' Thymidine (urine)
Dihydropyrimidinase (DHP) deficiency

Clinical: Similar to DPD deficiency, may be asymptomatic
Diagn.: ' Dihydrouracil, dihydrothymine (OA urine), ' uracil, thymine
Ureidopropionase deficiency
Clinical: Similar to DPD deficiency, dystonia
Diagn.: n–' Dihydrouracil, dihydrothymine (OA urine), n–' uracil, thymine; ' ureido-
propionate, .-alanine (may occur during analysis), ureidoisobutyrate
Other disorders of nucleotide metabolism
Nucleotidase hyperactivity (nucleotide depletion syndrome)

Clinical: Psychomotor retardation (mainly speech), seizures, ataxia, recurrent
infections, behavioural abnormalities (hyperactivity, short attention span, poor
social interaction)
Diagn.: & (or low normal) uric acid per creatinine, otherwise normal results including
purine and pyrimidine studies; enzyme analysis (fibroblasts)
Therapy: Uridine 50 mg/kg, increase up to 1 000 mg/kg (marked improvement in
speech, behaviour, epilepsy, frequency of infections)
Neurotransmission
Monogenic disorders of neurotransmission have become recognised as a cause of severe
early-onset progressive encephalopathies. The diagnosis is mostly based on the
quantitative determination of the neurotransmitters or their metabolites in CSF including
the amino acids glutamate, glycine and GABA and the metabolites of the biogenic
amines and pterins. The clinical presentation of neurotransmitter disorders is quite
distinct and they should not automatically be considered in every child with unexplained
encephalopathy. Neurotransmitter analyses are not indicated in isolated mental
retardation or pervasive developmental disorders. Several disorders (GABA-transaminase
deficiency, non-ketotic hyperglycinaemia, vitamin B6-responsive, pyridoxal phosphate-
responsive or folinic acid-responsive seizures) usually present with severe early-onset
epileptic encephalopathy. Disorders of the biosynthesis of dopamine result in progressive
extrapyramidal movement disorders. The spectrum of individual symptoms and disease
courses is wide, ranging from intermittent focal dystonia to “hereditary spastic diplegia”
and “cerebral palsy” to severe (lethal) infantile encephalopathies. For diagnostic
guidelines see page 42.
Disorders of biogenic amine metabolism
Biochemistry: Pterins GTP

GTPCH
A disturbance of biogenic amine metabo- Neopterin

PTPS
lism may be caused by a deficiency of
tetrahydrobiopterin (BH4), cofactor of the
SR
hydroxylation of tyrosine and tryptophan as
well as phenylalanine (see also PKU, page
71) and nitric oxide synthase (NOS). BH4 BH4 PAH,
is synthesised and regenerated by several DHPR TYH,
enzymes. BH2 = dihydrobiopterin. TPH,
BH2 PCD
For enzyme abbreviations see individual Biopterin
NOS
disorders.
Neurotransmission 145
Biochemistry: Biogenic amines

Aromatic L-amino acid decarboxylase catalyses the formation of serotonin as well as
dopamine; the latter may be converted by dopamine beta-hydroxylase into nor-
epinephrine and epinephrine. The breakdown of biogenic amines involves monoamine
oxidase-A and other enzymes.; 5-HIAA = 5-hydroxyindoleacetic acid; MHPG =
3-methoxy-4-OH-phenylglycol. For enzyme abbreviations see individual disorders.
Phenylalanine
BH4 PAH
Tryptophan Tyrosine
BH4 TPH BH4 TYH
3-O-Methyldopa Vanillactic acid
5-OH-Tryptophan L-Dopa
Vit. B6 AADC Vit. B6 AADC
DBH
Serotonin Dopamine Norepinephrine Epinephrine
MAO MAO MAO MAO
5-HIAA Homovanillic acid MHPG 5-Vanillylmandelic acid
Clinical features
$ General: Progressive/severe epileptic encephalopathy, myoclonic epilepsy,
psychomotor retardation,
$ Dopamine deficiency: Parkinsonism-dystonia, dyskinesia and hypokinesia, dystonia
and chorea, truncal hypotonia/limb hypertonia, may show typical deterioration during
the day, oculogyric crises, miosis, ptosis, hypomimia, hypersalivation
$ Norepinephrine deficiency: Axial hypotonia, cerebellar symptoms, miosis, ptosis,
Ļ blood pressure, hypoglycaemia
$ Serotonin deficiency: Insomnia, depression, disturbance of temperature regulation,
disturbed intestinal motility
Dopa-responsive dystonia (Segawa disease)

Clinical: Dystonia starting in first decade (or later)(incorrect diagnosis “athetoid or
dystonic cerebral palsy”); mostly pronounced diurnal variation.
Enzyme: GTP cyclohydrolase (dominant mutations, incomplete penetrance)
Diagn.: Biogenic amines + pterins (CSF); normal Phe (consider Phe challenge, page
50)
Therapy: L-Dopa 4–12 mg/kg/day; this usually achieves (almost) complete remission
within weeks
Tetrahydrobiopterin (BH4) deficiency (“atypical phenylketonuria”)

Clinical: Features of dopamine and serotonin deficiencies
Enzymes: $ GTP cyclohydrolase I (GTPCH; recessive mutations)
$ 6-Pyruvoyl-tetrahydropterin synthase (PTPS)
$ Dihydropteridine reductase (DHPR)
$ Pterin carbinolamine dehydratase (PCD)
$ Sepiapterin reductase (SR)
Diagn.: N–' Phe (plasma; normal particularly in SR deficiency; see also page 54);
biogenic amines (CSF), pterins (CSF, urine; see page 37); enzyme studies
(DHPR in dried blood spot, all in fibroblasts)
Therapy: $ L-Dopa 8–12 mg/kg/day (neonates 1–3 mg/kg/day, infants 4–7 mg/kg/day),
always with a decarboxylase inhibitor (e.g. carbidopa: 10–20% of L-dopa);
$ 5-OH-tryptophan (max. 6–9 mg/kg/day);
$ Tetrahydrobiopterin 5–10 mg/kg/day (monotherapy sufficient in mild PTPS
and PCD deficiencies)
$ Folinic acid 15 mg/day and Phe-restricted diet in DHPR deficiency
Caution: L-Dopa/carbidopa and 5-hydroxytryptophan should be introduced
sequentially and increased slowly in steps of not more than 1 mg/kg over
days/weeks. 5-OH-tryptophan may not be tolerated due to gastro-intestinal
side effects; monotherapy with L-dopa/carbidopa may be sufficient in these
cases.
Tyrosine hydroxylase (TYH) deficiency

Clinical: Severe dopamine deficiency
Diagn.: Biogenic amines (CSF)
Therapy: L-Dopa 1–10 mg/kg/day
Aromatic L-amino acid decarboxylase (AADC) deficiency

Clinical: Dopamine and serotonin deficiency
Diagn.: Biogenic amines (CSF); enzyme studies (plasma)
Therapy: Trihexyphenidyl, tranylcypromine, pergolide, Vit. B6, MAO inhibitors,
bromocriptine
Dopamine beta-hydroxylase (DBH) deficiency

Clinical: Norepinephrine deficiency, especially severe orthostatic hypotension
Diagn.: Biogenic amines (blood, urine and CSF); enzyme studies (plasma)
Therapy: Dihydroxyphenylserine
Monoamine oxidase (MAO) deficiency

Clinical: Aggressive behaviour, mild developmental retardation, stereotypic hand
movements, flushing (carcinoid syndrome)
Diagn.: Biogenic amines (CSF and urine); whole blood serotonin, enzyme studies
(fibroblasts)
Therapy: Cyproheptadine hydrochloride, sertraline hydrochloride (risk of aggravating
the serotonin/carcinoid syndrome)
Disorders of GABA metabolism
Biochemistry Glutamate
Vit. B6 Decarboxylase
Homocarnosine
Gamma-aminobutyric acid (GABA) is GABA and other
the major inhibitory neurotransmitter Vit. B6 Transaminase GABA conjugates
of the CNS above the brain stem level.
Both glutamate decarboxylase and Succinate
GABA transaminase are vitamin B6- semialdehyde 4-Hydroxybutyrate
dependent enzymes; for primary dis- SSADH
orders of pyridoxine metabolism see
page 148. Succinate
GABA Transaminase deficiency

Clinical: Neonatal fatal epileptic encephalopathy, psychomotor retardation, hypotonia,
macrosomia, tall stature (' STH)
Diagn.: AA (CSF): ' GABA; n–' homocarnosine, .-alanine
Succinic semialdehyde dehydrogenase (SSADH) deficiency

Clinical: Developmental retardation (mental, motor, language), hypotonia; seizures,
hyporeflexia, ataxia, hyperkinesis, aggressive behaviour; sometimes autistic
features, microcephaly/macrocephaly; MRI abnormalities (T2 hyperintensities
in the globus pallidus and the white matter)
Diagn.: OA (urine): ' 4-hydroxybutyric acid (excretion decreases with age; this may
cause false negative results in semiquantitative analysis in older individuals);
enzyme studies (fibroblasts, lymphocytes)
Therapy: Symptomatic, experimental Vigabatrin (may increase epilepsy)
Progn.: Satisfactory
Disorders of pyridoxine metabolism
Biochemistry
Pyridoxine Pyridoxal Pyridoxamine
PK PK PK
PNPO PNPO
Pyridoxine-P Pyridoxal-P Pyridoxamine-P
Membrane-associated phosphatases
Cellular uptake
PK
Intracellular pyridoxal-phosphate
Pyridoxal phosphate (PALP; vitamin B6) is cofactor of transamination and decarboxy-

lation reactions in various pathways including serotonin and dopamine biosynthesis. It
is synthesised from dietary pyridoxal, pyridoxamine and pyridoxine; enzymes involved
include pyridoxal kinase (PK) and pyridox(am)ine 5ǯ-phosphate oxidase (PNPO).
Pyridoxine-(vitamin B6-)responsive seizures

Recessively inherited pyridoxine-responsive seizures may be heterogeneous. Their
aetiology is unclear. They are are not caused by a deficiency of glutamate decarboxylase,
although they are often associated with increased glutamate and decreased GABA
concentrations in CSF.
There is no universal protocol for a pyridoxine challenge; high doses may be necessary at
least initially to control seizures. Suggestion: start with a single dose 100 mg i.v.; if
patient is non-responsive, give additional 100 mg doses every 10 min up to 500 mg total.
If there is uncertainty about at least a partial response, pyridoxine 30 mg/kg/day should
be continued for seven days before final conclusions are drawn.
Clinical: Epileptic encephalopathy presenting on day 1–2(–28); seizures respond only
to pyridoxine. There are however three atypical presentations:
Variants: 1) Late onset, i.e later than 28 days
2) Neonatal onset, initial response to conventional anticonvulsant therapy
3) Neonatal onset, response to pyridoxine initially negative, later positive
Diagn.: Sustained cessation of seizures on pyridoxine; AA (CSF): & GABA, ')Glu
Therapy: Maintanance dose: 5–10–15 mg/kg/day oral
Pyridoxal phosphate-responsive seizures

Clinical: Refractory neonatal seizures not responsive to pyridoxine but to pyridoxal
phosphate; microcephaly, muscle hypotonia
Enzyme: Pyridox(am)ine 5ǯ-phosphate oxidase (PNPO)
Diagn.: Sustained cessation of seizures on pyridoxal phosphate
AA (CSF): ')Thr, Gly; biogenic amines (CSF) mimicking AADC deficiency;
OS (urine): ')vanillactic acid; mutation studies
Therapy: Pyridoxal phosphate 30 mg/kg/day oral in 3 doses (no pharmaceutical
preparation available)
Other neurotransmitter defects
Folinic acid-responsive seizures

Clinical: Treatment-resistant seizures, neonatal onset; cardiomyopathy
Diagn.: Sustained cessation of seizures on folinic acid; biogenic amines (CSF)
Therapy: Folinic acid 3 mg/kg/day i.v. in 3 doses, long-term oral medication %
cessation of seizures, satisfactory development
Glucose transport protein deficiency (GLUT1 deficiency)

Clinical: Infantile epileptic encephalopathy, microcephaly, psychomotor retardation
Diagn.: & Glucose (CSF), glucose ratio CSF/blood < 0.35 (normal 0.65 / 0.1),
n–& lactate
Therapy: Ketogenic diet
Progn.: Good with early treatment
Hyperekplexia
Clinical: Exaggerated startle response, muscular hypertonia, generalised stiffness,
normal EEG
Protein: Į1-Subunit of the glycine receptor
Genetics: Autosomal dominant and recessive inheritance
Diagn.: Mutation analysis (GLRA1 gene); AA (CSF): & GABA
Therapy: Clonazepam
Other metabolic pathways
Porphyrias
Biochemistry
Biosynthesis of haem from glycine and succinyl-CoA involves eight different enzymes
and takes place mainly in the bone marrow (85%) and liver. Haem is metabolised to
bilirubin and excreted via bile. Porphyrias are disorders of haem biosynthesis, mostly
caused by autosomal dominant enzyme defects.
Clinical features
The accumulation of specific intermediary metabolites causes typical abdominal,
neurological and dermatologial symptoms. Hepatic and erythropoietic porphyrias are
distinguished according to the primary origin of the pathological metabolites. The
congenital erythropoietic porphyria (Günther disease) is characterised by typical
discolouration of the urine (brown, red-fluorescent spots in the nappies).
Triggers of acute crises (acute hepatic porphyrias) include various drugs (particularly
enzyme inducers), hunger, stress, alcohol, hormones and menstruation.
Investigations
$ Screening tests for porphobilinogen in urine (Hoesch test, Watson-Schwartz test)
when acute hepatic porphyria is suspected
$ Specific analyses (see page 37):
– Urine (particularly in hepatic porphyrias and Günther disease): Porphyrin
precursors ('-aminolaevulinic acid and porphobilinogen) and porphyrins (uro-,
hepta- [hexa-, penta-] and coproporphyrin)
– Faeces: Coproporphyrin (mainly isomer I), protoporphyrin
– Erythrocytes (particularly in protoporphyria): Cytosolic enzymes ('-amino-
laevulinic acid dehydratase, uroporphyrinogen-III synthase, porphobilinogen
desaminase, uroporphyrinogen decarboxylase)
Acute intermittent (hepatic) porphyria

Clinical: Abdominal colics with vomiting, acute abdomen; polyneuropathy
Manif.: 20–40 yrs, Ƃ > ƃ (2:1), often asymptomatic
Enzyme: Porphobilinogen deaminase (autosomal dominant)
Diagn.: Porphyrins/precursors ('-aminolaevulinic acid, porphobilinogen) in urine
Therapy: Avoid triggers. Acute attacks: Intensive care monitoring, analgesia
(chlorpromazine, pethidine and opiates), antiemetics (promazine), i.v. glucose
(4–6 g/kg/day), haemin-arginate (3 mg/kg as short infusion over 4 days)
Other metabolic pathways 151
Porphyria cutanea tarda (chronic hepatic porphyria)

Clinical: The most common porphyria: Photosensitivity, skin fragility; liver disease
Manif.: Mostly adult
Enzyme: Uroporphyrinogen-III decarboxylase
Diagn.: Porphyrins in urine (' uroporphyrin and heptaporphyrin) and faeces
Therapy: Avoid exposure to sunlight and other precipitating factors, use sunblock,
phlebotomy or better chloroquine (low dose, 2 x 125 mg/wk)
Congenital erythropoetic porphyria (Günther disease)

Clinical: Red urine, photodermatosis, dental discolouration, splenomegaly, anaemia
Manif.: Neonatal to childhood
Enzyme: Uroporphyrinogen-III cosynthase
Diagn.: Porphyrins in urine (isomer I), faeces and blood
Erythropoietic (-hepatic) protoporphyria

Clinical: Photosensitivity, chronic skin changes, liver abnormalities
Enzyme: Ferrochelatase
Manif.: Childhood and adolescence
Diagn.: Protoporphyrins in blood and faeces, porphyrins in urine
Therapy: Photoprotection, .-carotene; liver complications: Cholestyramine, bile acids
Disorders of transport or utilisation of metals
Wilson disease (hepatolenticular degeneration)

Clinical: Chronic liver disease, jaundice, cirrhosis; Kayser-Fleischer ring; dysarthria,
poor co-ordination % bulbar paralysis; renal problems, haemolysis
Manif.: 6–18 yrs (liver disease), 20–40 yrs (neurological symptoms)
Enzyme: (Hepatic) copper ATPase
Bioch.: & Biliary copper excretion, & incorporation of copper into coeruloplasmin;
accumulation of copper in liver, basal ganglia, kidneys
Diagn.: Serum: (n–)& coeruloplasmin, n–& copper; ' copper (urine); liver biopsy
(')copper); isotope studies (& incorporation into coeruloplasmin)
Therapy: Avoid copper in food and drinking water (fish, liver); zinc, trientene;
D-penicillamine (may cause hypersensitivity, bone marrow depression,
autoimmune and connective tissue diseases); consider liver transplantation.
Monitor: Free copper = total copper – [coeruloplasmin x 3.15]; urine copper
Menkes disease
Clinical: Neonatal hypothermia, severe jaundice % retardation, epilepsy, typical facies,
“kinky” hair, connective tissue/bone abnormalities % fatal (80–95%)
Var.: Milder course: Psychomotor retardation
Occipital horn syndrome: Connective tissue abnormalities (juvenile–adult)
Enzyme: (Non-hepatic) copper ATPase (X-linked)
Bioch.: Copper deficiency % deficiency of the (~ 13) copper enzymes
Diagn.: Serum: & copper, coeruloplasmin
Therapy: With early diagnosis: Daily copper injections
Acoeruloplasminaemia
Clinical: Diabetes mellitus, retinopathy, extrapyramidal signs, dementia
Bioch.: Deficient coeruloplasmin synthesis
Diagn.: Serum: Normal copper, && coeruloplasmin, & iron
Progn.: Fatal in adulthood
Acrodermatitis enteropathica
Clinical: Typical skin rash, mucosal lesions, total alopecia, irritability, mood changes
Bioch.: & Intestinal zinc absorption (transporter defect)
Diagn.: & Zinc, (may be normal); & alkaline phosphatase
Therapy: Zinc
Selenium
Selenium is a component of the following enzymes:
$ Several glutathione peroxidases, see page 83
$ Type I 5'-iodothyronine deiodinase (converts T4 to T3)
Deficiency: Clinical relevance uncertain; may be a cause of (cardio)myopathies
Molybdenum
Cofactor of sulphite oxidase and xanthine oxidase: See page 77 and 141.
Manganese
Cofactor of prolidase, see page 85; deficiency state not known.
Miscellaneous progressive neurological disorders
Primary vitamin E deficiency

Clinical: Spinocerebellar degeneration (ataxia, polyneuropathy, pyramidal tract lesion),
retinopathy, ophthalmoplegia, progressive retardation
Bioch: !-Tocopherol transfer protein (autosomal recessive)
Diagn.: & Vitamin E (plasma)
DD: Nutritive vitamin deficiency, pancreatic failure, abetalipoproteinaemia
Therapy: High-dose vitamin E (monitor plasma levels)
Thiamine (vitamin B1) deficiency

Thiamine is required for acetylcholine synthesis and is a cofactor for the transketolation
or decarboxylation of oxoacids (e.g. PDH and KDHC, page 91; BCKDH, page 73,
transketolase in the pentose phosphate pathway, page 107). Thiamine deficiency is not
infrequent in children with metabolic disorders or other critical illness and is endemic in
underdeveloped countries (beriberi).
Clinical: Fatigue, irritability, poor concentration, anorexia, nausea; neurological
abnormalities, hoarseness, ocular signs, ataxia, psychiatric disturbances
(Wernicke encephalopathy); congestive heart failure
Diagn.: ' Lactate (blood, CSF), ' glyoxylate (blood, urine); & transketolase activity
(erythrocytes); clinical response to thiamine treatment
Therapy: Thiamine 10–2 000 mg oral/i.m./i.v.
LTC4 synthase deficiency

Leukotrienes comprise a group of biologically highly active lipid mediators that are syn-
thesised predominantly from arachidonic acid through the 5-lipoxygenase pathway. They
include the cysteinyl leukotrienes (LTC4, LTD4, LTE4) and LTB4. Leukotriene synthesis
may be affected by disorders of the gamma-glutamyl cycle (see page 83). Leukotriene
analysis in CSF or other body fluids is not universally available.
Clinical: Progressive psychomotor retardation, hypotonia, no visual contact, failure to
thrive, microcephaly
Diagn.: & LTC4 (CSF), normal glutathione status, & LTC4-synthesis in nucleated cells
Choreoacanthocytosis (neuroacanthocytosis)
Clinical: Progressive dementia, epilepsy, involuntary movements, chorea, dystonia,
dysarthria and dysphagia, self-mutilative behaviour, peripheral neuropathy
Genetics: VPS13A gene; autosomal recessive, somtimes dominant inheritance
Diagn.: ' CK, normal lipoproteins. Peripheral blood smear: acanthocytosis
DD: Huntington disease, Wilson disease or primary tic disorders;
for the differential diagnosis of acanthocytosis see page 29.
McLeod syndrome
Clinical: Little or no reaction with various antisera in the Kell blood group system;
somtimes late-onset (cardio)myopathy, slowly progressive neuropathy,
movement disorder, epilepsy, psychiatric symptoms
Genetics: X-linked recessive, XK gene coding for the Kell blood group precursor Kx
Diagn.: ' CK, normal lipoproteins. Peripheral blood smear: acanthocytosis
DD: For the differential diagnosis of acanthocytosis see page 29.
Sjögren-Larsson syndrome
Clinical: Spastic diplegia/tetraplegia, mental retardation, epilepsy, photophobia, short
stature;
ichthyosiform keratoses (large skin folds, palmoplantar) from birth onwards
Enzyme: Fatty alcohol:NAD+ oxidoreductase
Diagn.: Enzyme activity in cultured skin fibroblasts or leukocytes, ' leukotriene B4 in
urine, mutation analysis
Ataxia teleangiectatica
Clinical: Progressive cerebellar ataxia from early childhood, progressive apraxia of eye
movements, choreoathetosis; telangiectasias of the skin and bulbar
conjunctiva, increased susceptibility to sinopulmonary infections,
lymphoreticular and other malignancies
Protein: Member of the phosphatidylinositol-3 kinase family involved in DNA repair
Genetics: Autosomal recessive; ATM gene
Diagn.: ' Serum alpha-fetoprotein, peripheral lymphopenia, & IgA, IgE, or IgG2,
radioresistant DNA synthesis in cultured fibroblasts, mutation analysis
DD: Friedreich ataxia, primary vitamin E deficiency, Marinesco-Sjögren syndrome
Therapy: Intravenous gammaglobulin therapy and postural drainage; no live-virus
vaccines
Miscellaneous disorders with mostly hepatic presentation
!1-Antitrypsin deficiency
!1-Antitrypsin (AAT) is one of the most important inhibitors of proteases (e.g. elastase,
trypsin, chymotrypsin, thrombin, bacterial proteases) in plasma. There are various
different protein variants that are differentiated by isoelectric focussing.
Clinical: Neonatal cholestasis, later cirrhosis, hepatocellular carcinoma; > 30 yrs:
Chronic bronchitis, emphysema
Variants: M = wild type; S = mutation E264V, slightly reduced AAT concentration;
Z = mutation E342K, allele frequency 0.5–2%, homozygous: Severe AAT
deficiency (deficient AAT secretion, aggregation in endoplasmic reticulum)
Diagn.: & AAT (serum – normal range approx. 80–400 mg/dl); isoelectric focussing
Therapy: Symptomatic; prevent active and passive smoking
Haemochromatosis
Accumulation of iron in parenchymal cells may be caused by a variety of conditions.
Primary haemochromatosis is most frequently caused by HFE gene mutations. Another
autosomal recessive form (HFE type 3) is caused by mutations in the transferrin receptor
2 (TFR2) gene, whilst a dominant form is caused by mutations in the ferroportin
(SLC11A3) gene (HFE type 4). Secondary forms may be found e.g. in haemolytic
anaemias requiring frequent transfusions.
Diagn.: Serum: '-'' transaminases, ferritin, iron, transferrin saturation;
increased hepatic iron content; mutation studies
Therapy: Regular venesection, deferoxamine; avoid vitamin C
Hereditary haemochromatosis (HFE type 1)

Clinical: Hepatosplenomegaly, liver cirrhosis, hepatocellular carcinoma; arthropathy,
cardiomyopathy, pituitary dysfunction (hypogonadism), diabetes mellitus,
hyperpigmentation
Manif.: Age 40–50, male > female
Protein: HFE = regulator of iron uptake by transferrin
Genetics: Autosomal recessive, common mutations C282Y and H63D in the HFE gene
Juvenile haemochromatosis (HFE type 2)

Clinical: Severe iron overload; cardiomyopathy may predominate; abdominal pain in
the first decade
Genetics: Autosomal recessive; common mutation G320V in the HFE2 gene
Proteins: Hemojuvelin = modulator of hepcidin expression; hepcidin inhibits intestinal
iron uptake and iron release from macrophages (few families)
Neonatal haemochromatosis
Clinical: Hepatopathy of prenatal onset, neonatal liver failure, usually rapidly fatal;
iron storage in various organs except reticulo-endothelial system
Genetics: Heterogenic
Therapy: Liver transplantation
Crigler Najjar syndrome (CNS) & Gilbert syndrome

Clinical: CNS type I: Severe neonatal jaundice, kernicterus, bilirubin encephalopathy
CNS type II: Usually benign, rarely bilirubin encephalopathy
Gilbert: Benign; intermittent jaundice usually first noted in adolescence
Enzyme: Bilirubin UDP-glucuronosyltransferase (bilirubin-UGT)
Genetics: Autosomal recessive; UGT1A1 gene
CNS type I: severe mutations, type II: milder mutations
Gilbert: homozygous TA insertion in the TATA box plus additional factors
Diagn.: Serum: '-'' unconjugated (indirect) bilirubin (CNS type I: bilirubin up to
50 mg/dl, no conjugated bilirubin); otherwise normal laboratory results,
normal liver function tests, no haemolysis;
Phenobarbital reduces bilirubin levels in Crigler Najjar type II and Gilbert
Incidence: Gilbert: 8% of the general population
Therapy: Phototherapy, plasmapheresis, liver transplantation (CNS type I)
Progressive familial intrahepatic cholestasis (PFIC)

Clinical: Jaundice, pruritus, growth retardation, hepato-(spleno-)megaly, progressive
cirrhosis
Variants: Byler disease = PFIC type I
PFIC type IV: see bile acid biosynthesis disorders, page 130
Protein: Different hepatobiliary transport proteins
Diagn.: Mixed, predominantly conjugated hyperbilirubinaemia; ' transaminases, ' AP,
GGT usually normal (except PFIC type III)
Therapy: Liver transplantation
Dubin-Johnson syndrome
Clinical: Mild jaundice, usually first noted in adolescence, occasionally
hepatosplenomegaly
Protein: Canalicular multispecific organic anion transporter (CMOAT)
Genetics: Autosomal recessive; ABCC2 gene
Diagn.: Mixed, predominantly conjugated hyperbilirubinaemia; normal liver function
tests; deposition of melanin-like pigment in otherwise normal liver cells
Therapy: None required
Rotor syndrome
Clinical: Same as in Dubin-Johnson syndrome
Protein: Unknown
Diagn.: Clinical chemistry as in Dubin-Johnson syndrome, different organic anion
transport abnormalities, no liver pigmentation
Alagille syndrome
Clinical: Typical facies, eye anomalies, congenital heart defects, vascular anomalies,
vertebral anomalies; growth failure, renal disease, malabsorption
Genetics: Autosomal dominant, mutations in JAF1 gene or monosomy 20p11
P'genesis: Bile duct hypoplasia; disturbance of Notch signalling pathway
Diagn.: Conjugated hyperbilirubinaemia
Therapy: Liver transplantation in severe hepatic disease
Other metabolic disorders
Trimethylaminuria (TMA-uria, fish odour syndrome)

Clinical: Unpleasant fish-like body odour due to volatile free trimethylamine (may
increase with high choline diet, carnitine treatment etc.); possibly deficient
breakdown of biogenic amines and certain drugs; adrenergic reactions
Enzyme: Flavin-containing monooxygenase isoform 3 (FMO3)
Genetics: Autosomal recessive; common variant allele [E158K, E308G] with reduced
enzyme activity (allele frequency 20%) causes mild TMA-uria
Diagn.: ' Free TMA (urine), & ratio oxidised:free TMA (norm > 90%); mutation
analysis
Dimethylglycinuria
Clinical: One patient with body malodour as in trimethylaminuria, muscle fatigue
Enzyme: Dimethylglycine dehydrogenase
Diagn.: ' CK; NMR spectroscopy (urine): ' Dimethylglycine
157
Appendix
Helpful internet resources
Societies
$ Society for the Study of Inborn Errors of Metabolism (http://www.ssiem.org.uk/)
$ Society for Inherited Metabolic Disorders (http://www.simd.org)
Disease-oriented databases
OMIM (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM)
This is the online version of “Mendelian Inheritance in Man”, the oldest and most widely
used collation of genetic disorders.
Orphanet (http://www.orpha.net)
This is a French/European database that contains information on a large number of
genetic and non-genetic conditions as well as diagnostic services.
Rare Genetic Diseases in Children (http://mcrcr2.med.nyu.edu/murphp01)

This internet jump-station contains links to various sources of information on rare
genetic diseases affecting children.
Diagnostic laboratories
EDDNAL (http://www.eddnal.com/)
The website of the European directory of DNA laboratories that offer molecular tests for
genetic disorders, supported mainly by funding from the European Commission.
GeneTests (http://www.genetests.org)
GeneTests is a predominantly North American list of laboratories that offer molecular
tests for genetic disorders.
Genomic information and mutation data

National Center for Biotechnology Information (http://www.ncbi.nlm.nih.gov/)
One of the main sources of molecular information on the internet.
Ensembl (http://www.ensembl.org/)
This is a very useful genome database maintained by the EMBL and Sanger Institute.
Human Genome Variation Society (http://www.genomic.unimelb.edu.au/mdi/);

Human Gene Mutation Database, HGMD (www.uwcm.ac.uk/uwcm/mg/hgmd0.html)
These websites provide links to various locus-specific databases that provide mutation
data and other information on individual genes and disorders.
158 Appendix
Free fatty acids and 3-hydroxybutyrate during fasting
Age-dependent normal values
= Free fatty acids (mean values)

mmol/L = 3-Hydroxybutyrate (mean values)
0
15 hrs. 20 hrs. 24 hrs. 15 hrs. 20 hrs. 24 hrs. 15 hrs. 20 hrs. 24 hrs.
Age: 1-12 months 1-7 years 7-15 years
Shown are mean values and 10–90 percentiles for free fatty acids (plasma) and
3-hydroxybutyrate (deproteinised blood) in children after 15, 20 and 24 hrs fasting. Data
from Eur J Pediatr 150 (1990) p. 80–5, with permission from Springer Verlag.
Correlation between free fatty acids and 3-hydroxybutyrate
4
Free fatty acids (mmol/l)
Hypoketosis
Normal range
(95 % predictive interval)
1
Hyperketosis
0,5
0,03 0,1 0,3 1 3

3-Hydroxybutyrate (mmol/l)
Shown is the correlation between the concentrations of free fatty acids (plasma) and
3-hydroxybutyrate (deproteinised blood) in children after a 24-hr fast. Adapted from
Arch Dis Child 75 (1996) p. 115–9, with permission from BMJ Publishing Group.
159
Index
A Amylo-1,4%1,6- Branched-chain AA
Abetalipoproteinaemia 138 transglucosylase 105 Maple syrup urine dis. 70
Acanthocytosis 29 Amylo-1,6-glucosidase 105 Metabolism 64
Acatalasaemia 126 Andersen disease 105 Organic acidurias 65
Acetoacetyl-CoA lyase 98 Anderson disease 138 Brand reaction 31
Acetylgalactosamine-4- Angiokeratoma 112 Byler disease 155
sulphatase 116 Antitrypsin, !1- 154
Acetylgalactosaminidase 117 Antley-Bixler syndrome 128 C
Acetylglucosamyl ApoB 138
ApoCII 137 Canavan disease 68
phosphotransferase 121 Carbamylphosphate
Acid lipase 121 ApoE variants 136
Apolipoprotein AI 137 synthase I 63
Acid maltase 105 Carbohydrate metabolism
Acid-base status 11 Arabinosuria 107
Arginase 63 100
Acidosis 11 Carboxylase deficiency,
Acoeruloplasminaemia 152 Argininaemia 63
Arginine:glycine multiple 69
Acrodermatitis enteropathica Cardiomyopathy 16
152 amidinotransferase 99
Argininosuccinate Carnitine
Acylcarnitines 34 Acylcarnitine carrier 95
Neonatal screening 55 Lyase 63
Synthase 63 Analysis 34
Acyl-CoA dehydrogenase Deficiency, primary 95
Long-chain hydroxy- 96 Argininosuccinic aciduria 63
Arylsulphatase A 119 Palmitoyltransferase 95
Medium-chain 96 Translocase 95
Short-chain 96 Arylsulphatase B 116
Aspartoacylase 68 Transporter 95
Short-chain hydroxy- 110 Uptake deficiency 95
Very long-chain 96 Aspartylglucosaminuria 117
Ataxia teleangiectatica 154 Carnosinaemia 85
Adenine phosphoribosyl- Carnosinase 85
transferase 142 ATP synthase 86
Cbl defects 78
Adenosine deaminase 141 CDG 131
Adenosylcobalamin 77 B Analyis 36
Adenylosuccinase 140 Barth syndrome 66, 92 Type Ia 132
Adrenoleukodystrophy Basic laboratory tests 1 Ceramidase 120
Neonatal 125 Beckwith-Wiedemann Ceramid-Trihexosidase 120
X-linked 125 syndrome 109 Cerebrotendinous
Alanine 13 Benzoate, Na- 10 xanthomatosis 130
Aldolase B 102 Beta-oxidation Ceroid lipofuscinoses 123
Alkaptonuria 72 Mitochondrial 93 Cherry-red spot 112
Allopurinol test 51 Peroxisomal 125 CHILD syndrome 128
Alpers syndrome 92 BH4 see Tetrahydrobiopterin Chitotriosidase 114
Alpha-1-antitrypsin 154 Bile acids Cholestasis 19
ALTE 24 Analysis 35 Cholesterol
Amino acids Biosynthesis 130 Decreased 138
Analysis 31 Peroxisomal disorders 124 Elevated 135
Metabolism 57 Biogenic amines 144 Chondrodysplasia punctata
Transport disorders 82 Analysis 42 Differential diagnosis 126
Aminoadipic aciduria 75 Biotin metabolism 69 Rhizomelic form 125
Ammonia 8 Biotinidase 69 X-linked dominant 129
160 Index
Chondroitin sulphate 115 E Galactosaemia 102

Choreoacanthocytosis 153 E3 deficiency 91 Galactose
Chylomicronaemia 137 Encephalopathy, epileptic 15 Analysis 35
Chylomicrons 134 Enzyme studies 39 Metabolism 100
Cirrhosis 23 ETF 97 Neonatal screening 53
Citrullinaemia 63 ETF-QO 97 Galactose-1-phosphate
Type II 64 Ethylmalonic uridyltransferase 102
CLN 123 Aciduria 68 Galactosialidosis 119
Cobalamin 77 Encephalopathy 68 Galactosidase
Malabsorption 78 Exercise intolerance 16 Alpha- (A) 120
COG complex 133 Alpha- (B) 117
Conjunctival biopsy 39 Beta- 118
Conradi-Hünermann 129 F Galactosyltransferase 133
Copper ATPase 151 Fabry disease 120 GALT 102
Cori disease 105 Fanconi-Bickel disease 106 Gammaglutamyl
Costeff syndrome 66 Farber disease 120 Cycle 83
CPEO 92 Fasting test 46 Transpeptidase 84
Creatine 98 Fatty acid analysis Gammaglutamylcysteine
Transporter 99 Free 35 synthetase 84
Crigler Najjar syndrome 155 Free (fasting) 158 Gangliosidosis 118
CSF-analyses 42 Very long-chain 37 Gaucher disease 119
Cystathionine Fatty acid metabolism 93 GDP-fucose transporter 133
Beta-synthase 77 Disorders 94 Gilbert syndrome 155
Gamma-lyase 77 Ferrochelatase 151 Glucagon Test 48
Cystathioninuria 77 Fibroblasts 39 Glucocerebrosidase 119
Cysteinylglycinase 84 Fish odour syndrome 156 Glucokinase 110
Cystinosis 122 Fish-eye disease 138 Gluconeogenesis disorders
Cystinuria 82 Floppy infant 15 103
Fetal hydrops 26 Glucose
Folic acid cycle 75 Blood concentration 6
D
Folinic acid-responsive Challenge 45
Dehydrocholesterol 129 seizures 149 Metabolism 100
Dehydrogenase deficiency, Forbes disease 105 Transport 108
multiple 97 Forearm ischaemia test 52 Transporter 1 149
Dermatan sulphate 115 Formiminotransferase 73 Transporter 2 106
Desmosterol reductase 128 Fructokinase 101 Glucose-6-phosphatase 104
Desmosterolosis 128 Fructose Glucose-galactose
Dihydrolipoamide DH 91 1,6-Bisphosphatase 103 malabsorption 108
Dihydropteridine reductase Intolerance 102 Glucosidase 133
146 Metabolism 100 Glucosuria, renal 108
Dihydropyrimidinase 142 Fruktosuria, essential 101 Glucosyltransferase 133
Dihydropyrimidine DH. 142 Fucosidosis 117 Glucuronidase 116
Dimethylglycinuria 156 Fumarase 91 GLUT 108
Dipeptidase, cysteinylglycine Fumaric aciduria 91 Glutamate DH 110
84 Fumarylacetoacetase 72 Glutaric aciduria
Dolicholphosphate-mannose Function tests 44 Type I 67
synthase 133 Type II 97
Dopamine "-hydroxylase 146 Glutaryl-CoA DH 67
Dopamine deficiency 145 G
Glutathione
Dopa-responsive dystonia GABA
Analysis 35
145 Analysis 32
Synthetase 84
Dubin-Johnson syndrome Metabolism 147
Glycerokinase 106
156 Transaminase 147
Glycerol
Dysbetalipoproteinaemia 136 Galactocerebrosidase 120
Intolerance 106
Dysmorphy 18 Galactokinase 102
Metabolism 100
Index 161
Glycine 79 3-Hydroxybutyrate Infant death, sudden 24

Cleavage System 80 Analysis 35 Insulin 109
Receptor 149 Fasting 158 Internet resources 157
Glycogen 3-Hydroxyisobutyric aciduria Intrinsic factor 78
Metabolism 100 67 Isobutyric aciduria 67
Storage diseases 104 3-Hydroxyisobutyryl-CoA Isobutyryl-CoA DH 67
Synthase 106 deacylase 70 Isovaleric aciduria 66
Glycosaminoglycans 36, 115 4-Hydroxybutyric aciduria Isovaleryl-CoA DH 66
Glycosidase 105 147
Glycosylation studies 36 Hydroxykynureninuria 75 J
Glykosaminoglykane 115 Hydroxylysinuria 75
Greenberg dysplasia 128 Jamaican vomiting sickness
Hydroxysterol, 3" see Sterol
GTP cyclohydrolase 145, 146 68
Hyperammonaemia 8, 61
Guanidinoacetate Jaundice
Emergency therapy 9
methyltransferase 98 Infantile 22
Long-term therapy 62
Günther disease 151 Neonatal 21
Maintenance therapy 10
Gyrate atrophy 81 Hypercholesterolaemia 135
ApoB-100 deficiency 135 K
H Familial 135 Kearns-Sayre syndrome 92
Polygenic 136 Keratan sulphate 115
Haemochromatosis 154
Secondary 136 Keto- see Oxo-
Hartnup disease 82
Hyperekplexia 149 Ketones
Hawkinsinuria 73
Hyperglycinaemia 80 3-OH-Butyrate (fasting)
HDL 134
Hyper-IgD syndrome 128 158
Elevated 138
Hyperinsulinism 109 3-OH-Butyrate analysis 35
Heparan sulphate 115
Focal 110 Ketogenesis 97
Hepatic lipase 136
Hyperleucine-isoleucinaemia Ketolysis 98
Hepatomegaly 19
70 Ketostix 12
+ Hypoglycaemia 22
Hyperlipidaemias 136 Metabolism 93
+ Splenomegaly 22
Hyperlipoproteinaemia, Ketosis 12
Hers disease 105
familial combined 136 Kir6.2 110
Hexosaminidase 118
Hyperlysinaemias 75 Krabbe disease 120
HHH syndrome 63
Hyperoxaluria type I 126
Histidase 73
Hyperprolinaemia 81
Histidinaemia 73
Hypertriglyceridaemia 137
L
HMG-CoA Lactate 13, 87
Hyperuricaemic nephropathy
Lyase 97 Lactic acidosis 87
141
Synthase 97 Lamin B receptor 128
Hypervalinaemia 70
Holocarboxylase synthetase L-amino acid decarboxylase
Hypobetalipoproteinaemia
69 146
138
Homocarnosinosis 85 Lanosterolosis 128
Hypoglycaemia 6
Homocysteine Lathosterolosis 129
Hypoprolinaemia 81
Analysis 32 LCAD 96
Hypotonia, muscular 15
Metabolism 75 LCHAD 96
Hypoxanthine:guanine phos-
Mild elevation 76 LDL 134
phoribosyltransferase 141
Homocystinuria 77 Receptor 135
Homogentisate dioxygenase Lecithin:cholesterol
72 I acyltransferase 138
Hunter disease 115 I-cell disease 121 Leigh syndrome 91
Hurler disease 115 IDL 134 Lesch-Nyhan syndrome 141
Hyaluronidase 116 Iduronat-2-sulphatase 115 Leukocytes (enzyme studies)
Hydrops 26 Iduronidase 115 39
2-Hydroxyglutaric aciduria Imerslund-Gräsbeck Leukotrienes 153
D-form 69 syndrome 78 LHON 92
L-form 68 Iminoglycinuria 82 Lipid storage disorders 121
162 Index
Lipogranulomatosis 120 Methylbutyric aciduria 67 Neuraminic acid 36

Lipoprotein (a) 135 Methylbutyryl-CoA DH 67 Neuraminidase 118
Lipoprotein lipase 137 Methylcobalamin 77 Neuroacanthocytosis 153
Lipoprotein metabolism 134 Methylcrotonyl-CoA Neuronal ceroid
Liver biopsy 39 carboxylase 66 lipofuscinoses 123
Liver disease 19 Methylcrotonylglycinuria 66 Neurotransmitter
Cholestasis 19 Methylene-FH4 reductase 76 Analysis 42
Chronic hepatitis 23 Methylglutaconic acidurias Disorders 144
Cirrhosis 23 66 Niemann-Pick disease
Hepatomegaly 19 Methylglutaconyl-CoA Type A, B 119
Infants 23 hydratase 66 Type C, D 121
Jaundice 21 Methyl-hydroxybutyryl-CoA Nitroprusside test 31
neonatal 21 DH 67 Norepinephrine deficiency
Liver phosphorylase 105 Methylmalonic aciduria 66 145
Kinase 105 Methylmalonyl-CoA mutase Nucleoside phosphorylase
LTC4 synthase 153 66 141
Lysine 74 Mevalonate kinase 128 Nucleotide depletion
Lysinuric protein intolerance Mevalonic aciduria 128 syndrome 143
64, 82 Mitochondrial disorder 87 Nukleotidase hyperactivity
Lysosomal disorders 111 MNGIE 92 143
Diff. diagnosis 112 Molecular genetics 40
Lipid storage 121 Molybdenum cofactor 77 O
Transport 122 Monoamino oxidase 146
Lysosomal studies 36 Morquio disease 116 Odour 27
MSUD 70 Oligosaccharides 36
MtDNA depletion 92 Oligosaccharidoses 117
M Organic acids 33
MTHFR 76
Malonic aciduria 69 MTP 96 Organic acidurias 65
Manganese 152 Mucolipidin 1 121 Cerebral 67
Mannosidosis Mucolipidoses 121 Ornithine 81
Alpha- 117 Mucopolysaccharides 36 Aminotransferase 81
Beta- 117 Mucopolysaccharidoses 115 Transcarbamylase 63
Mannosyltransferase 133 Mucosulphatidosis 120 Orotic acid, analysis 36
&1,3 133 Multiple Orotic aciduria 142
&1,6 133 Carboxylase deficiency 69 Oxoacid dehydrogenase 70
"1,4 133 Dehydrogenase defic. 97 Oxoglutarate DH 91
Maple syrup urine disease 70 Sulphatase deficiency 120 Oxoprolinase 84
Maroteaux-Lamy disease 116 Muscle Oxoprolinuria 84
MCAD 96 AMP deaminase 141 Oxosterol 5"-reductase 130
McArdle disease 105 Phosphofructokinase 105 Oxothiolase 98
McLeod syndrome 153 Phosphorylase 105 Oxysterol 7&-hydroxylase
MELAS 92 Muscle biopsy 39, 89 130
Menke disease 152 Mutation analyses 40
MERRF 92 Myoadenylate deaminase 141 P
Metabolic crisis 3
Palmitoyl-protein thioesterase
Triggers 2
N 123
Metabolic Profiling 44
N-Acetylglucosaminyl Pearson syndrome 92
Metachromatic
transferase 133 Pelger-Huët anomaly 128
leukodystrophy 119
N-Acetylglutamate synthase Pentose metabolism 107
methacrylic acid 70
64 Pentosuria 107
Methionine 75
NARP 92 Peptidase
Synthase 76
Natowicz disease 116 Pepstatin-insensitive 123
Methyl group transfer 75
Neonatal screening 53 Peptidase B 85
Methyl-acyl-CoA racemase
Nesidioblastosis 109 Peptide metabolism 85
126
Index 163
Perchloric acid extraction 38 Purines Serine 79

Peroxisomal disorders 124 Analysis 37 Serotonin
Phenylacetate, Na- 10 Disorders 140 Analysis 38
Phenylalanine Metabolism 139 Deficiency 145
Challenge 50 Pyridoxal phosphate- SGLT 108
Hydroxylase 71 responsive seizures 148 Sialidosis 118
Metabolism 71 Pyridoxamine 5ǯ-phosphate Sialinic acid storage 122
Neonatal screening 54 oxidase 148 SIDS 24
Phenylbutyrate, Na- 10 Pyridoxine Simple urine tests 30
Phenylketonuria 71 Metabolism 148 Sitosterolaemia 136
Atypical 146 -responsive seizures 148 Skin biopsy 39
Maternal 72 Pyrimidine 5'-nucleotidase Sly disease 116
Phosphatidylinositol-3 kinase 142 Smith-Lemli-Opitz syndrome
154 Pyrimidines 129
Phosphoenolpyruvate Analysis 37 Sphingolipidoses 118
carboxykinase 103 Disorders 142 Sphingomyelinase 119
Phosphoglycerate DH 79 Metabolism 139 SSADH deficiency 147
Phosphomannomutase 133 Pyrroline carboxylate Sterol
Phosphomannose isomerase Dehydrogenase 81 !14-Reductase 128
133 Synthase 81 !24-Reductase 128
Phosphoribosyl-PP synthetase Pyruvate 13 !5-Desaturase 129
140 Analysis 38 !7-Reductase 129
Phosphoserine phosphatase Carboxylase 103 !8,!8-Isomerase 129
79 Dehydrogenase 91
14&-Demethylase 128
Phytanic acid 37, 124 Metabolism 86
27-Hydroxylase 130
Phytosterolaemia 136 Pyruvoyl-tetrahydropterin
4-Demethylase 128
PKU 71 synthase 146
Analysis 38
Plasmalogens 37, 124
Biosynthesis 127
Pompe disease 105 R Succinic semialdehyde DH
Porphobilinogen deaminase
R-binder 78 147
150
Reducing substances 30 Succinyl-CoA:3-oxoacid-CoA
Porphyrias 150
Refsum disease 126 transferase 98
Porphyrin analysis 37
Infantile 125 Sudden infant death 24
Post-mortem investigations
Respiratory chain 86 Sulphatase deficiency,
25
Retardation, psychomotor 14 multiple 120
Pristanic acid 37, 124
Reye-syndrome 24 Sulphatidase 119
Profiling, Metabolic 44
Ribose-5-P isomerase 107 Sulphite oxidase 77
Progressive familial
Rotor syndrome 156 Sulphite test 31
intrahepatic cholestasis
Sulphur AA 75
155
SUR1 110
Prolidase 85 S
Proline 81 Salla disease 122
Oxidase 81 Sandhoff disease 118 T
Propionic aciduria 65 Sanfilippo disease 116 Tandem MS 55
Propionyl-CoA carboxylase Sarcosinaemia 80 Tangier disease 138
65 SCAD 96 Tauri disease 105
Protein glycosylation 131 SCHAD 110 Tay-Sachs disease 118
Protein requirements 59 Scheie disease 115 Tetrahydrobiopterin
Protoporphyria 151 Schindler disease 117 Deficiency 146
Pseudo-Hurler dystrophy 121 SCOT 98 Metabolism 144
Pterin carbinolamine Segawa disease 145 Test 49
dehydratase 146 Selenium 152 Thiamine deficiency 153
Pterins analysis 37 Sengers syndrome 92 Thymidine phosphorylase
Sepiapterin reductase 146 142
164 Index
Tocopherol transfer protein U VLCAD 96

153 UDP-galactose epimerase VLCFA 124
Transaldolase 107 102 VLDL 134
Transcobalamin II 78 Urea cycle 61 Von Gierke disease 104
Tricarboxylic acid cycle 86 Ureidopropionase 142
Disorders 91 Uric acid 140 W
Trifunctional protein 96 Uridine monophosphate
Triglycerides Wilson disease 151
synthase 142 Wolfram syndrome 92
Decreased 138 Urine colour and odour 27
Elevated 137 Wolman disease 121
Urocanase 73
Transfer protein 138 Uroporphyrinogen-III
Trimethylamine analysis 38 Cosynthase 151 X
Trimethylaminuria 156 Decarboxylase 151 Xanthine oxidase 141
Tryptophan 74 Xanthinuria 141
2,3-Dioxygenase 74 Xylitol dehydrogenase 107
Tryptophanaemia 74 V
Tyrosinaemia 72 Vitamin
Tyrosine B1 (thiamine) 153 Z
Aminotransferase 72 B12 (cobalamin) 77 Zellweger syndrome 125
Hydroxylase 146 B6 (pyridoxine) 148
Metabolism 71 B6-dependent seizures 148
E (tocopherol) 153

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Inside front cover

Patterns of acute presentation

Main problem See page

Important laboratory findings

Main problem See page

Drug Preparation Dose (emergency administration)

Special emergency medication

Drug Preparation Dose (emergency administration)

Johannes Zschocke, Heidelberg

Georg F. Hoffmann, Dr. med. habil.

This edition corresponds to the third German and Italian editions.

Bibliographic information published by Die Deutsche Bibliothek

Important note: Medicine is an ever-changing science, so the contents of this

Edited and Preparations of the camera-ready manuscript by the authors

It is a pleasure to write a foreword to the latest edition of the Vademecum Metabolicum.

Forword to the 1st edition

Inborn errors of metabolism, which cumulatively affect approximately one in 500

Heidelberg, August 2004 Johannes Zschocke

Diagnosis and management of metabolic disorders..............1

Essential basic laboratory tests .......................................................................1

General clinical situations.................................................................................3

Special metabolic investigations....................................................................30

Neonatal screening ..........................................................................................53

Metabolic pathways and their disorders ............................... 57

Amino acid and protein metabolism...............................................................57

Energy metabolism ..........................................................................................86

Carbohydrate metabolism .............................................................................100

Peroxisomal metabolism ...............................................................................124

Sterol metabolism ..........................................................................................127

Protein glycosylation .....................................................................................131

Purine and pyrimidine metabolism...............................................................139

Other metabolic pathways.............................................................................150

AA amino acids OH- hydroxy-

Diagnosis and management of

Essential basic laboratory tests

Urinary ketones (ketostix)

Other laboratory tests

Specific triggers of metabolic decompensation

Triggers Groups of disorders

General clinical situations

The metabolic emergency

A metabolic disorder should be considered, along with other diagnoses (e.g.

Appropriate diagnostic and therapeutic measures must be initiated as soon as possible

Post-mortem investigations: See page 25.

Phase 1: Basic metabolic emergency investigations

Stop intake of potentially toxic compounds (protein, fat, galactose, fructose)

Obtain urine sample:

If lumbar puncture is performed:

Order additional investigations as indicated, e.g. ECG, echocardiogram, cranial imaging.

Phase 2: Treatment and investigations according to the initial findings

If the emergency investigations show ...

If results are inconclusive but metabolic disease remains a possibility:

Hypoglycaemia Glucose concentration:

Laboratory investigations during symptomatic hypoglycaemia

As always: There are exceptions to every rule or simplification.

Ketones “normal” (low) or Free fatty acids relatively low: Hyperinsulinism,

Hyperammonaemia NH3 concentration: µmol/l = µg/dl x 0.59

NH3 values: Neonates: Healthy < 110 µmol/l

It is essential to measure ammonia early in every sick child in whom a metabolic

Emergency investigations and differential diagnosis

Plasma Other features Diagnosis

Organise all treatment options as soon as hyperammonaemia is confirmed. Extra-

First infusion (over 2 hrs)

Check glucose, add insulin if necessary; check ammonia after 2 hrs.

Ketones “normal” (low) or Free fatty acids relatively low: Hyperinsulinism,

Normal values: pH 7.37–7.43

Most disorders of intermediary metabolism (“small molecule disorders”) cause symptoms

Unexpected findings in “routine” laboratory tests require critical evaluation. Particularly