The Journal of Pediatrics Hicks et al. 5 9 9 Volume 127, Number 4

marion: an hypothesis based upon cytoarchitectural analysis. Acta Neuropathol 1978;41:109-17.

11. Shimozawa N, Tsukamoto T, Suzuki Y, et al. A human gene responsible for Zellweger syndrome that affects peroxisome assembly. Science 1992;255:1132-4.

12. Dodt G, Braverman N, Wong C, et al. Mutations in the PTS1

receptor gene, PXR1, define complementation group 2 of the peroxisome biogenesis disorders. Nature Genetics 1995;9:115- 25.

13. G~rtner J, Moser H, Valle D. Mutations in the 70K peroxiso- mal membrane protein gene in Zellweger syndrome. Nat Genet 1992;1:16-23.

Heterozygosity for long-chain 3-hydroxyacyl- coenzyme A dehydrogenase deficiency and deterioration in liver function in a newborn infant infected with human immunodeficiency virus

Patricia Hicks, MD, Michael J. Bennett, PhD, MRC Path, Janet Squires, MD, and Octavio Ramilo, MD From the Departments of Pediatrics, Pathology, and Microbiology, University of Texas Southwestern Medical Center at Dallas

A child with perinatally acquired human immunodeficiency virus infection had rapidly progressive hepatic dysfunction, as had her older sibling who died. Uri- nary organic acid studies revealed 3-hydroxydicarboxylic aciduria, and cultured skin fibroblasts had reduced activity of 3-hydroxyl-coenzyme A dehydrogenase. The introduction of a low fat diet resulted in marked improvement in clinical status and reversal of the liver disease. This case illustrates the necessity of metabolic evaluation in patients with liver dysfunction, even when other causes of liver dys- function are present. (J PEDIATR 1995;127:599-602)

Hepatic dysfunction is an infrequent complication in chil- dren with perinatally acquired human immunodeficiency virus infection. Hepatic injury may result directly from HIV infection or from accompanying problems such as malnutri- tion, medications, or opportunistic infections. 1, 2 We report

a pefinatally HIV-infected child who had, as did her sibling, progressive hepatic dysfunction associated with heterozy- gosity for long-chain 3-hydroxyacyl-coenzyme A dehydro- genase deficiency. Homozygosity for L-CHAD deficiency represents a very severe disorder of the mitochondrial [3-ox- idation of fatty acids that is frequently associated with end- stage hepatic failure. 36 In this heterozygote, HIV may have

been instrumental in the clinical expression of liver failure

Submitted for publication Feb. 13, 1995; accepted June 9, 1995. Reprint requests: Patricia Hicks, MD, Department of Pediatrics, Children's Medical Center of Dallas, 1935 Motor St., Dallas, TX 75235. Copyright © 1995 by Mosby-Year Book, Inc. 0022-3476/95/$5.00 + 0 9/22/66926 '

in a manner analogous to the association of L-CHAD heterozygosity with the maternal syndrome of hemolysis,

elevated liver enzyme values, and low platelet count (HELLP).7, 8

C A S E R E P O R T

The patient is the fourth child born to an HIV-infected woman. The third child (the first HIV-infected child) had rapid deterioration

AIDS ALT AST CoA H1V L-CHAD

Acquired immunodeficiency syndrome Alanine aminotransferase Aspartate aminotransferase Coenzyme A Human immunodeficiency virus Long-chain 3-hydroxyacyl--coenzyme A

dehydrogenase deficiency

of liver function at 6 months of age and died at 2 years of age of complications of rapidly progressive HIV disease. Antemortem liver biopsy had revealed giant cell hepatitis without lipid deposi- tion; the cause was presumed to be HIV infection. This patient was born at 32 weeks of gestation, weighing 1800 gm, with Apgar scores

6 0 0 Hicks et al. The Journal of Pediatrics October 1995

1.0e+07.

8.0e+06-

6 .0e+06-

, < 4 . 0 e + 0 6 -

O.Oe+O0" lb 1'2 1~ io i~ 2'0

19

24

22 23

20 21

12 17

14 18

.2'2 2'4 2g 2~ 3'0 32 3~ 4b ~ g8 5'2 5'6 6'0 Time (min.)

Figure. Regenerated total ion chromatogram of urinary organic acid analysis in the patient before the introduction of a reduced dietary fat intake. Peak identities are as follows: (1) lactate, (2) 3-hydroxybutyrate, (3) succinate, (4) internal stan- dard, (5) thymine, (6) 3-hydroxyadipic acid lactone, (7) adipate, (8) unsaturated adipate (probably), (9) heptanedioate, (10) octenedioate plus 3-hydroxyadipate, (11) octanedioic, (12) aconitate, (13) hippurate, (14 and 15) unsaturated 3-hydroxy- decanedioate, (16) decanedioate, (17) vanillylmandelic acid, (18) unsaturated 3-hydroxydecandedioate, (19) 3-hydroxyde- canedioate, (20) urate, (21 and 22) unsaturated 3-hydroxydocecanedioate, (23) 3-hydroxydodecanedioate, (24) internal standard. The large unlabeled peak at the end of the chromatogram is a glucuronide. This pattern was not seen in other chil- dren with HIV infection.

of 4 at 1 and 10 minutes. This mother s urine contained metabolites for cocaine and opiates at the time of delivery. The polymerase chain reaction amplification for HIV was positive when the infant was 2 weeks of age. When the P24 antigen increased to 4800 pg/ml and the CD4 + cell count fell to 835 cells/mm 3 at 5 months of age, treatment was begun with zidovudine, 180 mg/m 2 per dose; at that time, her liver enzyme values were elevated (alanine aminotrans- ferase, 267 U/L; aspartate aminotransferase, 540 U/L). At 9 months her development was markedly delayed. Her liver function deteri- orated (maximum ALT 704 U/L, AST 3044 U]L). Her CD4 + cell count decreased to 370 cells/mm 3. Results of hepatic ultrason- agraphy were normal, the Otl-antitrypsin test result was negative, and results of serologic studies for viral hepatitis were negative. At 11 months of age she had a single generalized seizure, and inves- tigations revealed normal blood ammonia, glucose, lactate, and anion gap values, normal urinanalysis results, and normal results on electroencephalographic and cerebrospinal fluid studies, including tests for cryptococcal antigen, acid-fast bacteria, and fungal and bacterial cultures. Serum copper and ceruloplasmin values were normal at 16 and 170 pmol/L, respectively. Her det liver function deteriorated, with prolongation of her prothrombin time to 15.7 seconds, and her partial thromboplastin time to 59.6 seconds, and she began having episodes of lower intestinal tract bleeding. Urine studies revealed a nonspecific amino acid pattern consistent with liver dysfunction, and an organic acid pattern of nonketotic medi- m-cha in dicarboxylic (adipic, snberic, sebacic) and 3-hydroxydi- carboxylic (3-hydroxyadipic, -suberic, -sebacic, dodecanedioic, and unsaturated tetradecanedioic) acidaria consistent with L-CHAD deficiency (Figure). A liver biopsy revealed the same histologic findings as in her sibling (i.e., enlarged hepatocytes with vesicular cytoplasm and frequent multinucleation. Scattered cytoplasmic bile

pigmentation without intracanalicular bile plugs was identified. There was no significant steatosis. After the patient's diet was changed to a fat-restricted formula, AST activity decreased from 3044 to 1112 U/L, ALT from 641 to 327 U/L, and serum bilirubin concentration from 250 to 220 pmol/L (14.5 to 12.9 mg/dl) in 2 weeks. Three weeks later, her ALT activity was 121 U/L, AST ac- tivity 524 U/L, and total bilirnbin concentration 154 pmol/L (9.0 mg/dl), and her bleeding episodes ceased. Her prothrombin and partial thromoplastin times corrected to 11.9 and 37.7 seconds, re- spectively, within 2 months). Her cultured skin fihroblast studies revealed a reduced oxidation of [9,10-3H]palmitic acid to 10.2 pmol/min per milligram of protein (normal control values, 17.7 to 21.6), and oxidation of [9,10-3]myristic acid of 18.5 (normal con- trol values, 19.37 to 22.09). Activity of L-CHAD, with 3-keto- palmitoyl-CoA used as substrate, 9 revealed reduced activity of 70 nmol/min per milligram of protein at 37 ° C (mean of three assays); normal control values were 94 to 100 nmol/min per milligram of protein, and the value for a patient homozygons for the common G1528C mutation for L-CHAD deficiency was 21 nmol/min per milligram of protein; obligate heterozygotes for the G1528C muta- tion had 67 to 70 nmol/min per milligram of protein. Activity of short-chain 3-hydroxy acyl-CoA dehydrogenase and short-chain ketoacyl-CoA thiolase in our patient was normal. Molecular studies are under way to define the nature of the mutation. Prelim- inary experiments excluded the presence of the G1528C mutation.

D I S C U S S I O N

The pathway of mitochondrial fatty acid B-oxidation is an

important source of alternative energy when carbohydrate

The Journal of Pediatrics Hicks et al. 6 0 1 Volume 127, Number 4

levels are limited by decreased intake or increased demand or use, as seen during a febrile illness. Defects of this oxi- dative pathway result in hepatic or myopathic disease. 3-6 Hepatic symptoms may be acute and resemble a Reye syn- drome-like illness, as typified by the clinical pattern of me- dium-chain acyl-CoA dehydrogenase deficiency, 3 or may be chronic and progressive, as characterized by L-CHAD defi- ciency and with fulminant liver failure) -6 Myopathic symp- toms are generally associated with long-chain fatty acid oxidation and include both cardiac (hypertrophic cardio- myopathy) and skeletal (progressive muscle weakness) ab- normalities. Muscle involvement tends to be a more chronic or late feature.

Most liver function abnormalities in HIV-infected patients are related to hepatotropic opportunistic infections or med- ication-induced hepatic insults. However, liver disease dur- ing the first 6 months of life is relatively rare, and the like- lihood that two children in the same family would have sig- nificant 1 iver disease from HIV infection alone was therefore low. This suggested to us the possibility of an underlying in- herited disorder as the cause of the progressive liver disease. It seems likely that the liver disease was related to the un- derlying heterozygosity for L-CHAD deficiency, which may have been precipitated by the HIV infection or treatment. Heterozygosity for L-CHAD deficiency has been implicated in the acute fatty liver of pregnancy (hemolysis, elevated liver enzymes, low platelet count [HELLP syndrome]) L 8; it is believed that the additional metabolic burden of pregnancy in a heterozygote is sufficiently stressful to precipitate liver dysfunction usually found only in homozygous disease. It is possible that the additional metabolic stress of HIV infection and potentially hepatotoxic drugs could precipitate a meta- bolic dysfunction in a patient heterozygous for L-CHAD deficiency. This possibility was strongly supported when the pattern of liver dysfunction in our patient resolved rapidly when she was fed a diet containing predominantly carbohy- drate calories (the basis of treatment for most fatty acid ox- idation defects). At the same time as the resolution of the liver disease, she had abundant evidence of progressive HIV disease, with falling CD4 counts and increasing quantitative viral cultures of her plasma. Another possibility is that the HIV infection or the drug treatment in some way acted as a direct inhibitor of the L-CHAD enzyme, although both the index case and her sibling had progressive deterioration of liver function before any antiretroviral therapy. Moreover, urine samples have been screened for urine organic acids in our young HIV-infected patients receiving antiretroviral therapy, and these have been normal. Secondary L-CHAD deficiency also occurs in disorders affecting the availability of the essential cofactor nicotinamide adenosine dinucle- otide, in respiratory chain disorders, 1° and in glycogen stor- age disease type 3. I1 The observation of reduced fatty acid

oxidation in cultured cells in our patient supports a primary abnormality in fatty acid oxidation rather than a secondary abnormality, because the cells had been maintained in a sterile environment for multiple passages, and cells from patients with respiratory chain disorders have normal fatty acid oxidation. The high background enzyme activity is re- lated to the presence of peroxisomal L-CHAD activity; sim- ilar background activity has been reported in all previous case reports of L-CHAD deficiency. 4-7

The evaluation of hepatobiliary disease in children with HIV is similar to that for adults. 12 However, this may not be appropriate in the child who has liver disease in the first year of life, because onset of liver disease in HIV infection is as- sociated with long-term malnutrition, hypotensive insults, medications, sepsis, or opportunistic infections. 1,2 In the newborn infant, the differential diagnosis of progressive liver disease includes congenitally acquired diseases. Op- portunistic infections are more likely when ultrasonography shows focal lesions, or when cholangitis is present. 13 There is a case report of a 9-month-old infant with giant cell hep- atitis determined to be caused by HIV infection. 14 She had negative serologic findings for hepatitis B and Epstein-Ban" vires, and a liver biopsy culture negative for cytomegalo- virus, but no metabolic investigation was undertaken. Both our patient and her sibling had a pathologic diagnosis of gi- ant cell hepatitis, which is a nonspecific finding.

This case indicates that metabolic causes for deteriorating liver disease in the newborn infant should be considered even in the face of HIV infection. L-CHAD, in particular, appears to be sensitive to additional stress, even in the heterozygous state. Dietary alterations may markedly alter outcome, as in our patient.

R E F E R E N C E S

1. Bonacini M. Hepatobiliary complications in patients with HIV infection. Am J Med 1992;92:404-11.

2. Lebovics E, Dworkin BM, Heier SK, Rosenthal WS. The hepatobiliary manifestations of human immnnodeficiency vi- res infection. Am J Gastroenterol 1988;83:1-7.

3. Hale DE, Bennett MJ. Fatty acid oxidation disorders: a new class of metabolic diseases. J P E D ~ 1992; 121:1-11.

4. Hale DE, Thorpe C, Braat K, et al. The L-3-hydroxy acyl CoA dehydrogenase deficiency. Prog Clin Biol Res 1990;321:505- 10.

5. Wanders RJA, Ijlst L, van Gennip A, et al. Long-chain 3-hy- droxy acyl-CoA dehydrogenase deficiency: identification of a new inborn error of mitochondrial fatty acid oxidation, J Inher Metab Dis 1990; 13:311-4.

6. Jackson S, Singh-Kler R, Bartlett K. Combined enzyme defect of mitochondrial fatty acid oxidation. J Clin Invest 1992; 90:1219-25.

7. Wilcken B, Leung KC, Hammond J, Kamath R, Leonard JV. Pregnancy and fetal long-chain 3-hydroxyacyl-CoA dehydro- genase deficiency. Lancet 1993;341:407-8.

8. Treem WR, Rinaldo P, Hale DE et al. Acute fatty liver of preg,

6 0 2 Kagalwalla et al. The Journal of Pediatrics October 1995

nancy and long-chain 3-hydroxyacyl-CoA dehydrogenase de- ficiency. Hepatology 1994;19:339-45.

9. Wanders RJA, Ijlst L, Poggi F, et al. Human trifunctional pro- tein deficiency: a new disorder of mitochondrial fatty acid ox- idation. Biochem Biophys Res Commun 1992; 188:1139-45.

10. Bennett MJ, Weinberger MJ, Sherwood WG, Berlina AB. Secondary 3-hydroxydicarboxylic aciduria mimicking long- chain 3-hydroxyacyl-CoA dehydrogenase deficiency. J Inher Metab Dis 1994;17:283-6.

11. Bergoffen J, Kaplan P, Hale DE, Bennett MJ, Berry GT. Marked elevation of 3-hydroxydecanoic acid in a malnourished

infant with glycogen storage disease, mimicking long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency. J Inher Metab Dis 1993;16:851-6.

12. Cappell MS. Hepatobiliary manifestations of the acquired immune deficiency syndrome. Am J Gastroenterol 1991 ;86:1- 15.

13. Cello JP. Acquired immunodeficiency syndrome cholangiop- athy: spectnma of disease. Am J Med 1989;86:539-46.

14. Witzleben CL, Marshall GS, Wenner W, Piccofi DA, Barbour SD. HIV as a cause of giant cell hepatitis. Human Pathol 1988:19:603-5.

Phosphorylase b kinase deficiency glycogenosis with cirrhosis of the liver

Amir F. Kagalwalla,. MBBS, Yasmeen A. Kagalwalla, MBBS, FCAP, Sulaiman AI Ajaji, MD, Waldemer Gorka, MD, and M. Ashraf Ali, MD, FCAP From the Departments of Pediatrics, Pathology, and Medical Imaging, King Fahad National Guard Hospital, and the Department of Pathology, King Faisal Specialist Hospital, Riyadh, Saudi Arabia

We describe an Arab girl with complete absence of phosphorylase b kinase ac- tivity in the liver, symptomatic hypoglycemia, and persistently elevated serum aminotransferase values whose symptoms did not lessen with age; sequential liver biopsies showed progression to cirrhosis. Cirrhosis could not be ascribed to any other known cause. We conclude that type IX glycogenosis is not always asso- ciated with a benign outcome. (J PEDIATR 1995; 127:602-5)

Phosphorylase b kinase deficiency in human beings is a het- erogeneous group of disorders affecting the liver, muscle, and heart alone, or the liver and muscle together. Within this broad category, the hepatic PK glycogenoses (type IX) are disorders in which, in addition to the accumulation of gly- cogen in the liver and PK deficiency, the muscle may also be affected; on the basis of the associated muscle involve- ment and the pattern of inheritance, the disorders are subdi- vided into three subtypes: (1) type IXa, an X-linked reces- sive disorder with normal glycogen and PK activity in the muscle, (2) type IXb, an autosomal recessive disorder with normal muscle glycogen and PK, and (3) type IXc, an au- tosomal recessive condition with PK deficiency in the liver, muscle, erythrocytes, and leukocytes with excessive glyco-

Submitted for publication March 1, 1995; accepted June 12, 1995. Reprint requests: Amir F. Kagalwalla, MBBS, Consultant Pediatric Gastroenterologist, 1255 Arrowood Court, Aurora, IL 60504. Copyright © 1995 by Mosby-Year Book, Inc. 0022-3476/95/$5.00 + 0 9/22/67087

gen content in all these tissues. 1-6 Long-term follow-up studies in PK deficiency hepatic glycogenosis have shown that these patients achieve normal growth, regression of hepatomegaly, and resolution of symptoms. 7

We describe a girl with complete absence of PK enzyme in the liver and erythrocytes, severe clinical manifestations, and unremitting biochemical features with progression to cirrhosis. To our knowledge, cirrhosis has not been described with PK deficiency glycogenosis.

PK Phosphorylase b kinase [

M E T H O D S

Fresh liver and muscle tissues were immediately frozen and transported in dry ice to our reference laboratory (Bioscientia, Mainz, Germany). Tissues were also fixed in 10% buffered formalin for light microscopy and in 2% glu- taraldehyde for electron microscopy. Paraffin-embedded tissue sections were routinely stained with hematoxylin-and- eosin stain periodic acid-Schiff reagent, and trichrome stain.