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DR.AHMED HOZAYEN
INBORN ERRORS OF
METABOLISM
Recognize IEM in a neonate with non-specific signs and symptoms
Make use of simple lab tests in the diagnosis of IEM
Initial management of life threatening conditions associated with IEM
Objectives
Inborn Errors of Metabolism
3
An inherited enzyme deficiency leading to the disruption of normal body metabolism
Accumulation of a toxic substrate (compound acted upon by an enzyme in a chemical reaction)
Impaired formation of a product normally produced by the deficient enzyme
4
Affects amino acid & protein, carbohydrate, and lipid metabolism.
Most disorders are autosomal recessive in transmission
Most disorders are evident at or soon after birth.
Early detection and treatment are essential to the prevention of irreversible cognitive impairment and early death
What is a metabolic disease?
5
substrate excess
toxic metabolite
A
D
B C product deficiency
Disorders of: Amino acids Carbohydrates Fatty acid Lysosomal and peroxisomal function Mitochondrial Organic acids
Categories of IEM
Metabolic Diseases Can Grouped as
Defects of Carbohydrates-Glycogen storage disease(GSD), Galactosemia,
Defects of amino acids-Phenylketonuria(PKU), Alkaptonuria,Urea cycle defects(UCDs).
Organic acidemias-isovaleric acidemia, propoinic acidemia(PPA), methylmalonic acidemia(MMA), maple syrup urine disease(MSUD).
Defects of lipids-Mitochondrial fatty acid oxidation defects, peroxisomal disorders ,lysosomal disorders ,mucopolysaccharidoses.
Defects of purines and pyrimidines-Lesh-nyhan syndrome
Miscellaneous –wilson disease,alpha-1-anti trypsin deficiency.
Diagnosis/ Newborn Screening
◦ Nonselective screening – screening all newborns for a limited number of common inborn errors
◦ Selective – testing of an individual known to be at increased risk (e.g. sibling)
◦ Tandem mass spectroscopy – allows clinicians to screen for > 30 disorders
Clinical manifestations
◦Usually appear 24 hours or more after birth, attributed to ingestion of precursor substrate of defective enzyme
◦CNS symptoms, poor growth, failure to thrive, developmental delays, specific neurological deficits
◦May have blatant signs (i.e. unusual odor)
Abnormal urine odor
Lens dislocation : Sulfite oxidase deficiency
Miscellaneous
Skin changes : Biotinidase deficiency
Peroxisomal disorders : Zellweger syndromeLarge fontanelle prominent forehead flat nasal bridge epicanthal folds hypoplastic supraorbital
ridges
Dysmorphic Features
Pyruvate dehydrogenase deficiencyEpicanthal folds flat nasal bridge small nose with
anteverted flared alae nasi
long philtrum
Dysmorphic Features
Glutaric aciduria type IIMacrocephaly high forehead flat nasal bridge short anteverted nose ear anomalies hypospadias rocker-bottom feet
Dysmorphic Features
Cholesterol biosynthetic defects Smith-Lemli-Opitz
syndrome: Epicanthal folds, flat nasal
bridge, toe 2/3 syndactyly, genital abnormalities, cataracts
Dysmorphic Features
Congenital disorders of glycosylation: Inverted nipples, lipodystrophy
Lysosomal storage disorders: Hurler-like phenotype
Dysmorphic Features
Clinical manifestations – diagnosis◦ Laboratory studies ◦ Routine
Hypoglycemia, acid-base balance, hyperammonemia, ketosis
◦ Specialized studies Require special lab Directed analysis for amino acids or organic
acids
© 2007 Thomson - Wadsworth
Approaches to Treatment
In most cases, treatment needs to be instituted empirically without a specific diagnosis.
The metabolic screen helps to broadly categorize the patient’s IEM (e.g. urea cycle defect, organic academia,
congenital lactic acidosis etc), on the basis of which, empirical treatment can be instituted
Aims of treatment 1. To reduce the formation of toxic metabolites by
decreasing substrate availability (by stopping feeds and preventing endogenous catabolism)
2. To provide adequate calories. 3. To enhance the excretion of toxic metabolites. 4. To institute co-factor therapy for specific disease and
also empirically if diagnosis not established. 5. Supportive care- -Treatment of seizures (avoid sodium valproate – may increase ammonia levels), -Maintain euglycemia and normothermia, -Fluid, electrolyte & acid-base balance, -Treatment of infection, -Mechanical ventilation if required.
Management of hyperammonemia: 1) Discontinue all feeds. Provide adequate calories
by intravenous glucose and lipids. Maintain glucose infusion rate
8-10mg/kg/min. Start intravenous lipid 0.5 g/kg/day (up to 3 g/kg/day). After
stabilization gradually add protein 0.25 g/kg till 1.5 g/kg/day.
2) Dialysis is the only means for rapid removal of ammonia, and hemodialysis is more effective and faster than peritoneal dialysis. Exchange transfusion is
not useful.
3) Alternative pathways for nitrogen excretion-:
-Sodium benzoate. -Sodium phenylbutyrate -L-arginine (oral or IV) -L-carnitine (oral or IV) 4) Supportive care: Treatment of
sepsis,seizures,ventilation.
1. Determine if there is metabolic acidosis 2. Is anion gap >16? 3. Is there hypoglycemia? 4. Is there hyperammonemia?
◦ Within 24 HOL?◦ After 24 HOL?
Copyright ©1998 American Academy of Pediatrics
Healthy NB rapidly ill, ◦Ketoacidosis, poor feeding
Vomiting, dehydration Hypotonia, lethargy Tachypnea, seizures Coma, unusual odors
Organic acidemia
Labs: Urine organic acids Ketonuria (in the NB)- pathognomonic of
IEM Neutropenia, thrombocytopenia +/- hyperammonemia Abnormal acylcarnitine
Organic acidemia
Treatment: Stabilize Get rid of organic acid intermediates, and
ammonia- hemodialysis Carnitine After stabilization, may resume oral feeds Consult dietitian, and metabolic specialist
Organic acidemia
No acidosis (respiratory alkalosis) No ketones (unlike organic acidemia) No hypoglycemia But with hyperammonemia
Urea cycle disorder
Treatment: Remove ammonia Hydration with D10 + electrolytes D/C all protein x 24 hours—calories from
CHO and fat Na phenylacetate/Na benzoate Give arginine Protein restriction for life
Urea cycle disorder
Prognosis: guarded Even with Treatment, many will die Definitive treatment: liver transplant
Urea cycle disorder
Galactocemia
An inborn error of carbohydrate metabolism in which the hepatic enzyme (galactose-1-phosphate uridyl transferase), GALK1 or GALE, which normally converts galactose into glucose is absent.
Autosomal recessive pattern Incidence It occurs in approximately 1 out of
every 60,000
Dietary Lactose Galactose Galactose 1-Phosphate Glucose
BRAINMental retardation
LIVER Jaundice Hetaptomegaly Cirrhosis
EYEScataracts
Galactocemia: How does it happen?
Three forms of galactosemia
Galactose-1 phosphate uridyl transferase deficiency (classic galactosemia, the most common and most severe form)- (GALT) Type I
Deficiency of galactose kinase – (GALK1)Type II
Deficiency of galactose-6-phosphate –epimerase (GALE)-Type III
Jaundice, vomiting poor feeding infections Failure to thrive hepatomegaly Speech disabilities, mental retardation
Classic galactosemia – type I
Galactosemia clinical pictures
Clinical pictures of Galactosemia Type II
Mild Cataract in the
infant
How is treated galactosemia?
The only way to treat galactosemia is through dietary restrictions
from the first days of life No brest feeding Soya- based formula
• The newborn with questionable results on newborn screening should continue to be treated with soy-based formula pending definitive results of confirmatory testing.
Galactosemia screening Why? If unscreened and untreated,
galactosemia is a life-threatening disorder. When? Neonatal period: 4th day
How? Screening of every neonates, followed by confirming tests. Thereby, affected infants are treated before they become ill.
Phenylketonuria (PKU)
Phenylketonuria is a genetic disorder where the body’s enzyme, phenylalanine hydroxylase ,is missing or malfunctioning so that it cannot properly break down the amino acid, phenylalanine .
Mental Retardation Seizures Microcephaly (small head size) Skin rashes Stunted growth Hyperactivity “Musty or mousy” body odor from the
excess phenylalanline Fair skin, hair, and eyes (phenylalanine is
linked to melanin production)
Symptoms
PKU is usually diagnosed after birth with a blood test taken from the infant’s heel or the crook of their arm.◦ If there are abnormal amounts of phe, then
further tests (blood and urine) are taken to ensure that the child has PKU.
Another option of diagnosis is through the chorionic villus sampling (CVS) process.
Treatment & Prevention
TreatmentOnce diagnosed, babies are fed diets containing
protein without phenylalanine for the first 7-10 days.Special infant formula called Lofenalac
Recently, there’s been a special medical (pill) formula discovered for PKU patients called Kuvan.
It’s possible to have a wide range of PKU, from mild to severe, but it’s suggested to stick to a diet regiment for life.
Treatment & Prevention
There’s usually a general list of foods that should not be consumed for PKU patients like:◦ Dairy
Milk, eggs, Cheese◦ Nuts◦ Beans◦ Peas◦ Meat (Poultry, beef, pork, duck etc.)◦ Chocolate◦ the sweetener aspartame can act as poisons for
people with phenylketonuria
Treatment & Prevention
Prevention:Unfortunately, if PKU is already diagnosed in an infant, there are no preventive measures one can take for their child to not have PKU.If a pregnant individual has PKU, then she’s able to prevent her child from PKU symptoms if she follows a diet low in protein.
Treatment & Prevention
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Hurler syndrome type I
51
Causes of the Hurler syndrome
Inherited as an autosomal recessive trait caused by mutations in the IDU Agene
(4p16.3) Metabolic defect: inability
◦The body's to make an enzyme: lysosomal alpha-L-iduronase
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incidence & and risk factors
Approximately 1 in 150,000 infants are affected
Newborn infants with this defect appear normal at birth
By the end of the first year, signs of impending problems begin to develop
© 2007 Thomson - Wadsworth
Coarse facial features (86.4%) Corneal clouding (70.9%) Heaptomegaly (70.0%) Kyphosis/gibbus (70.0%) Hernias (58.9%) Airway-related symptoms, such as sleep
disturbances/snoring (51.6%) Splenomegaly (50.9%) Cardiac valve abnormalities (48.9%) Cognitive impairment (46.4%) Dystosis multiplex (43.6%)
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
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Hurler syndrome (type I)
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Key Symptom Images
Claw hand
Coarse facial features
Corneal clouding
Hernia
Mucopolysaccharidosis I (MPS I) Disease (Hurler, Hurler-Scheie, Scheie Syndromes)
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Hunter syndrome type II
(Sulpho-idoronide sulphatase deficiency )
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Hunter syndrome type II
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X-linkedCoarse, thick, facial featuresProgressive stiffness decreased mental development HepatomegalySplenomegalyAbnormal bone x-rays
Hunter syndrome type II
Thank you