CASE 1

A 45-year-old male with history of hepatitis C and now cirrhosis of the liver is brought to the
emergency center by family members for acute mental status changes. The family reports that
the patient has been very disoriented and confused over the last few days and has been nauseated
and vomiting blood. The family first noticed disturbances in his sleep pattern followed by
alterations in his personality and mood. On examination, he is disoriented with evidence of
icteric sclera. His abdomen is distended with a fluid wave appreciated. He has asterixis and
hyperreflexia on neurologic exam. His urine drug screen and ethyl alcohol screen are both
negative. A blood ammonia level was noted to be elevated, and all other tests have been normal.

QUESTIONS:
1. What is the most likely diagnosis? Justify your answer.

The most likely diagnosis HEPATIC ENCEPHALOPATHY SECONDARY TO

ELEVATED AMMONIA LEVELS.

Hepatic encephalopathy (HE) is the term used to encapsulate the broad spectrum of
neuropsychiatric disturbances associated with both acute and chronic liver failure (ALF and
CLF, respectively), as well as porto-systemic bypass in the absence of hepatocellular disease.
The clinical manifestations of HE can be extremely heterogeneous in nature, with symptoms
presenting anywhere on a continuum spanning from seemingly normal cognitive performance,
right the way through to states of confusion, stupor and coma. In between these extremes,
patients with HE may exhibit signs such as inattentiveness, blunted affect, impairment of
memory or reversal of the sleep–wake cycle, as well as physical manifestations such as tremor,
myoclonus, asterixis and deep tendon hyperreflexia.

Patient’s Signs and Hepatic Encephalopathy Signs and Symptoms

Symptoms

Very disoriented and confuse Difficulty in thinking, confusion and poor concentration

Nauseated Lethargy/ Drowsiness

Disturbance of sleep pattern Disruption of sleep pattern

Alteration in personality and Sudden change in personality/behavior

mood

Icteric Sclera Jaundice

Asterixis and Hyperflexia Psychomotor retardation

Slowly Flap their hands up and down when attempting to hold

their arms out

Elevated Blood ammonia Liver is not clearing ammonia from the bloodstream
level

** Ammonia is a by-product of nitrogen metabolism, and its formation in the body is

predominantly a consequence of the action of the enzyme glutaminase located within enterocytes
of the small intestine and colon, as well as the action of the vast number of urease-producing
bacteria located in the gut. Ammonia derived from the gut is absorbed into the hepatic portal
circulation and transported to the liver where, under normal physiological conditions, it enters
the urea cycle and is metabolized. Ammonia that bypasses this primary fate is subsequently
‘picked up’ and detoxified by glutamine synthetase (GS), an enzyme found in the hepatocytes
surrounding the hepatic vein (as well as in muscle and astroglial cells), which catalyses the
conversion of ammonia and glutamate to glutamine. Whilst the liver is critical in the homeostatic
control of blood ammonia levels, other organs such as the brain, muscle and kidney are also
known to play a role in regulating them. Insult to the liver, whether acute or chronic in nature,
reduces its capacity to metabolize ammonia and this exerts an ammonia burden on extrahepatic
tissues which can result in hyperammonaemia up to five times that of normal blood ammonia
levels.

2. Explain the biochemical basis of the patient’s condition.

The formation of urea in the liver is the most important

disposal route for ammonia. Therefore, extrahepatic ammonia
must be transferred to the liver. However, ammonia in the
blood is toxic to cells thus the nitrogen from amino acid
metabolism is transported as either Glutamine or Alanine. The
first mechanism of transport of ammonia is found in most
tissues wherein Glutamine is synthesized from the combination
of ammonia and glutamate catalyzed by glutamine synthetase.
The second mechanism of transport is used mainly by the
muscles and it involves the transamination of pyruvate to form
Alanine.
Through the blood, Glutamine and Alanine are
transported into the liver where they are taken up by cells in
the periportal region. Ammonia is released by the combined
action of either alanine transaminase or glutaminase
(depending on the amino acid) and glutamate dehydrogenase
(GDH). The α-amino group of Alanine is transferred to α-
ketoglutarate to form glutamate and pyruvate. Glutaminase
catalyzes the hydrolysis of the side chain amide group releasing ammonia and glutamate.
Ammonia and glutamate enter the mitochondria, where glutamate is oxidatively deaminated by
GDH. The ammonia that is released by glutaminase and GDH then enters the urea cycle.
When liver function is severely impaired or when collateral links between portal and
venous blood vessels arise such as in cirrhosis, the ability of the liver to detoxify ammonia to
urea is compromised resulting in hyperammonemia. When blood ammonia levels rise, ammonia
builds up inside the cells and drives the GDH reaction to form glutamate, thus depleting α-
ketoglutarate stores and slowing the tricarboxylic acid cycle (TCA cycle). Since the TCA cycle is
needed by the brain to produce energy, the depletion of α-ketoglutarate stores and the slowing
down of the TCA cycle affects normal brain function.

CASE 2

A 1-year-old girl is brought to her pediatrician’s office with concerns about her development.
She had an uncomplicated birth at term. The mother reports that the baby is not achieving the
normal milestones for a baby of her age. She also reports an unusual odor to her urine and some
areas of hypopigmentation on her skin and hair. On exam, the girl is noted to have some muscle
hypotonia and microcephaly. The urine collected is found to have a “mousy” odor.

QUESTIONS:
1. What is the most likely diagnosis? Justify your answer.

The most likely diagnosis is PHENYLKETONURIA.

Phenylketonuria (PKU), is an autosomal recessive disorder affecting chromosome 12.

This is cause by a deficiency of phenylalanine hydroxylase, is the most common clinically
encountered inborn error of amino acid metabolism.
Without the enzyme necessary to process phenylalanine, a dangerous buildup can
develop when a person with PKU eats foods that contain protein or eats aspartame, an
artificial sweetener. This can eventually lead to serious health problems.
For the rest of their lives, people with PKU — babies, children and adults — need to
follow a diet that limits phenylalanine, which is found mostly in foods that contain protein.
The disease acquired its name from the presence of a phenylketone (now known to be
phenylpyruvate) in the urine.

Phenylketonuria Patient’s Signs and Symptoms

Healthy at birth Uncomplicated birth at term
Delayed mental development and social Not achieving the normal milestones for a
skills baby of her age
(if not treated properly it may lead to
learning disabilities, behavioural
difficulties and epilepsy)
A “mousy” odor in the breath, skin or “mousy” odor unusual odor to her urine
urine, caused by too much phenylalanine in
the body
 Light skin, hair and eyes than brothers and Hypopigmentation on her skin and hair
sisters without the disease
Microcephaly Microcephaly
Hypotonia

Characteristics of classic Phenylketonuria (PKU):

A. Elevated phenyalalanine – phenylalanine is present in elevated concentration in
tissues, plasma and urine. The metabolites such as the phenyllactate, phenylacetate
and phenylpyruvate which are not normally produced in significant amounts in the
presence of functional phenylalanine hydroxylase, are elevated in PKU these give
urine a characteristic of musty (“mousey”) odor.
B. CNS symptoms – mental retardation, failure to walk or talk, epilepsy/seizures,
microcephaly and failure to grow are characteristic findings in PKU. This is due to
the accumulation of phenylalanine in brain impairs the transport and metabolism of
tryptophan and tyrosine. There is a failure or decreased serotonin synthesis by
tryptophan that leads to a defective synthesis of myelin sheath.
C. Hypopigmentation – patient’s with PKU often show a hypopigmentation on their skin
and hair because of the high levels of phenylalanine present in PKU that inhibits
hydroxylation of tyrosine by tyrosinase.

2. Explain the biochemical basis of the patient’s condition.

Phenylketonuria is a deficiency caused by a deficiency of phenylalanine hydroxylase (PAH) and
two other enzyme deficiencies namely, dihydropteridine reductase and 6-pyruvoyl-
tetrahydropteridine synthase. Biochemically, it is characterized by an accumulation of
phenylalanine, resulting in hyperphenylalanemia, and a deficiency of tyrosine. Phenylpyruvate
also accumulates and it is the cognate α-ketoacid of the amino acid, phenylalanine. I t is formed
by transaminating phenylalanine and α-ketoglutarate to yield glutamate and phenylpyruvate. For
large scale conversion of phenylalanine to phenylpyruvate, an increase in the concentration of
phenylalanine must occur which is a plasma phenylalanine level greater than 120 µmol/L. Figure
2. Phenylalanine Metabolic Pathway
 Phenylalanine hydroxylation is the pathway whereby dietary phenylalanine is converted
into tyrosine. It is catalyzed by phenylalanine hydroxylase and this is the principal enzyme of
this pathway located on chromosome 12 which means that any misfolded protein or mutation
that affects chromosome 12 would also impair the synthesis of phenylalanine hydroxylase.
Phenylalanine hydroxylase is dependent on the reduction of dihydrobiopterin to
tetrahydrobiopterin by dihydropteridine reductase. Thus any genetic or protein folding defect in
either dihydropteridine reductase or the biopterin biosynthetic enzymes would compromise the
efficacy of phenylalanine hydroxylation into tyrosine resulting to hyperphenylalanemia and
phenylketonuria due to increased transamination of phenylalanine to phenylpyruvate.

CASE 3

The mother of a 16-year-old female calls the clinic because of concerns about her daughter’s
eating habits. The mother states the she will not eat anything and is obsessed with exercise and
losing weight. She also states that her daughter has been more withdrawn from friends and
family. After discussion with the mother, the patient comes in for a physical examination. The
patient is 5 ft. 1 in. tall and weighs 85 lb. She is in no acute distress but appears to have a
depressed affect. The patient states she is worried that her friends will think she is fat if she eats
more. She denies any binge eating. Her physical examination is normal, other than dry skin and
thin fine hair on extremities. Laboratory tests reveal that she is anemic and has a low albumin
and magnesium level. She has normal liver and thyroid tests.

QUESTIONS:
1. What is the most likely diagnosis? Justify your answer.

 The most likely diagnosis is ANOREXIA NERVOSA.

Anorexia Nervosa Patient’s Signs and Symptoms

Behavioral Signs

Restriction of food intake ✓

Obsession with exercise and weight loss ✓

Physical Signs

Dry and brittle hair and nails

Dry skin ✓

Presence of lanugo ✓
 Overall weakness

Anemia (in severe cases) ✓

Slowed heart rate (in severe cases)

Kidney Failure (in severe cases)

Severely low blood pressure (in severe cases)

Loss in bone density (in severe cases)

Psychological Signs

Anxiety about body image ✓

Overall feelings of stress, anxiety, and depression ✓

2. Explain the effect of the patient’s condition on her amino acid metabolism.
Anorexia nervosa is a mental disorder wherein the patients see themselves as overweight
although their current weight us less than 30% under ideal body weight. There is no ingestion of
food and nutrients as a behavioral sign, is usually observed.

An important part of the daily diet we intake are nutrients, vitamins, minerals and essential
amino acids. Essential amino acids are not synthesized by humans and therefore are needed to be
ingested by food intake. These amino acids are used in synthesis of non protein biomolecules and
also participate in critical whole body processes such as interorgan nitrogen transfer and acid-
base balance.

However, in cases of prolonged fasting and insufficient nitrogen ingestion as seen in

Anorexia nervosa, negative nitrogen balance may happen. In this case, nitrogen excretion
exceeds ingestion. As a result, there will be an increased proteolysis, a non critical skeletal and
liver proteins preferential degradation to release utilizable amino acids and meet both
biosynthetic and energy needs of the body. Furthermore, when rates of amino acid are increased
as a result of prolonged caloric insufficiency, a large portion of the carbon skeleton is used by the
liver for synthesis of either glucose (gluconeogenesis) or ketone bodies (ketogenesis), depending
on the specific amino acid.
 Thus, instead of amino acids being used for biosynthetic purposes, there will be an increased
proteolysis of skeletal and liver proteins to be used as direct fuel source for ketogenesis and
gluconeogenesis.

CASE 4

A 37-year-old female presents to your clinic to discuss her plans for a new vegetarian diet. The
patient heard from a friend about a new vegetarian diet that promised rapid weight loss. The diet
consists of many leafy vegetables with no pork, chicken, beef, eggs, or milk. She is also planning
on working out regularly with the goal of running a marathon within the year. She asks you for
further assistance and guidance.

QUESTION:
1. What advice would you give to your patient regarding her planned diet?
The patient should be careful to ensure a balanced ingestion of proteins, carbohydrates, and
vitamins. With animal proteins, they mostly contain all the essential amino acids. Vegetable
proteins, however, often lack one or more of the essential proteins, resulting to a low biological
value and incomplete digestion. In addition, the patient’s vegetarian diet can easily meet the
deemed dietary protein requirements as long as the energy needs are met and a variety of foods
are eaten. Protein sources may come from soy products, grains, nuts, and seeds. Moreover, the
patient should eat foods that would complement each other in providing the essential amino acids
needed by the body. It is not necessary that these combinations should be eaten at every meal, as
long as a variety of foods are eaten from time to time.

2. Explain the effect of your patient’s planned diet on her amino acid metabolism.
Amino acids are the building blocks of proteins, which is needed in muscle building, creating
hemoglobin, repairing organs, and supporting the immune system. Most animal proteins contain
all the essential amino acids in comparison with vegetable proteins, which lack one or more.
Therefore, it is critical to have a continuous source of amino acids for protein synthesis, energy
utilization, and production of biological mediators. A diet lacking in amino acids, like that of the
patient, may have significant effects on her amino acid metabolism. If the amino acid arginine is
lacking in the diet, there may be problems in growth (growth retardation). Deficiency in the
essential amino acid lysine may increase the levels of anxiety. Another example would be
phenylalanine, which is an essential amino acid. Phenylalanine is used to generate tyrosine,
which is needed for protein synthesis. In the absence of the essential amino acid, tyrosine will
not be generated, thus becoming essential. Insufficient supply of essential amino acids would
lead to physical effects, (muscle wasting, decreased immune response, weakness, and fatigue)
mental effects (higher anxiety, retardation), and eventually may lead to Kwashiorkor disease.

REFERENCES

BOOKS
Attia, E., & Walsh, T. (2007). Anorexia Nervosa. Retrieved from
https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2007.07071151
Ferrier, D. (2014). Lippincott’s Illustrated Reviews: Biochemistry (6th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins
Harms, K.; Seifert, W.; Strobel, H. & Toy, E. (2008). Case Files Biochemistry. New York, NY:
The McGraw- Hill Companies
Marsh, K. A., Munn, E. A., & Baines, S. K. (2013). Protein and vegetarian diets. The Medical
Journal of Australia, 199(4), 7-10.