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Methylmalonic Acidemia with Homocystinuria Type cblX

MRX3

Homocystinuria with methylmalonic acidemia is a rare metabolic disorder. There are distinct types of the disease, with the most common one being homocystinuria with methylmalonic acidemia type cblC (HMMAC). HMMAC is inherited in an autosomal recessive manner and is caused by mutations in the MMACHC gene. Only recently, recessive X-linked inheritance has been reported for an HMMAC-like disease that couldn't be related to MMACHC mutations. It has been proposed to refer to this disorder as homocystinuria with methylmalonic acidemia type cblX (HMMAX).


Presentation

Most HMMAX patients appear normal at birth but small gestational age has been reported [1]. According to current knowledge, HMMAX manifests within the first few months of life; symptom onset beyond infancy is not uncommon in case of HMMAC but has yet to be described in HMMAX patients [2]. Affected infants are presented to the pediatrician with failure to thrive, severe developmental delays, and neurological symptoms. The spectrum of neurological deficits is broad and ranges from cognitive impairment to choreoathetosis and other movement disorders and anomalies of muscle tone. HMMAX patients commonly experience intractable seizures. Affected individuals may be microcephalic [1]. Psychiatric conditions and behavioral disorders, visual impairment, and peripheral neuropathy have repeatedly been observed in HMMAC patients but no such findings have been made in those suffering from HMMAX [1] [2] [3] [4]. Similarly, extraneural manifestations like cardiac malformation, cardiovascular accidents, renal involvement resulting in thrombotic microangiopathy and hemolytic uremic syndrome, gastrointestinal and dermatological symptoms, all of which have been associated with HMMAC, may eventually occur in HMMAX patients [4] [5].

Feeding Difficulties
  • Most patients suffering from homocystinuria with methylmalonic acidemia present within the neonatal period or infancy: Their parents may claim feeding difficulties and failure to thrive, and affected children show neurological deficits ranging from cognitive[symptoma.com]
  • When the condition begins early in life, babies have difficulty gaining weight ( failure to thrive ), feeding difficulties, and a pale appearance. Babies may also have weak muscle tone ( hypotonia ) and seizures.[rarediseases.info.nih.gov]
  • Patients with cblD present with severe learning difficulties, behavioral problems and movement and gait abnormalities and patients with cblF and cblJ present with feeding difficulties, hypotonia, stomatitis, mild facial dysmorphism, cardiac malformations[orpha.net]
  • Born after a normal pregnancy, the patient developed general hypotonia and severe feeding difficulties at 5 days of life.[analesdepediatria.org]
Movement Disorder
  • The spectrum of neurological deficits is broad and ranges from cognitive impairment to choreoathetosis and other movement disorders and anomalies of muscle tone. HMMAX patients commonly experience intractable seizures.[symptoma.com]
  • Before the onset of newborn screening, infants with the subtypes cblA or mut – would present with a devastating injury in the basal ganglia (more specifically lacunar infarcts in the globus pallidus) resulting in a debilitating movement disorder [ Korf[ncbi.nlm.nih.gov]
Short Stature
  • stature Decreased body height Small stature [ more ] 0004322 X-linked recessive inheritance 0001419 Showing of 15 Last updated: 7/1/2019 If you need medical advice, you can look for doctors or other healthcare professionals who have experience with this[rarediseases.info.nih.gov]
Failure to Thrive
  • Affected infants are presented to the pediatrician with failure to thrive, severe developmental delays, and neurological symptoms.[symptoma.com]
  • Clinical description The disease typically presents with failure to thrive, acute neurological deterioration, intellectual deficit, lethargy, seizures, microcephaly, a salt-and-pepper retinopathy, and signs of megaloblastic anemia (pallor, fatigue, anorexia[orpha.net]
  • Affiliated tissues include brain, and related phenotypes are failure to thrive and nausea and vomiting[malacards.org]
  • When the condition begins early in life, babies have difficulty gaining weight ( failure to thrive ), feeding difficulties, and a pale appearance. Babies may also have weak muscle tone ( hypotonia ) and seizures.[rarediseases.info.nih.gov]
  • Neonatal presentation of this condition includes failure to thrive, encephalopathy, psychomotor retardation, haematological abnormalities of the three series and renal damage 1.[revistanefrologia.com]
Visual Impairment
  • Psychiatric conditions and behavioral disorders, visual impairment, and peripheral neuropathy have repeatedly been observed in HMMAC patients but no such findings have been made in those suffering from HMMAX.[symptoma.com]
Muscle Hypotonia
Long Arm
  • This gene is located on the long arm of the X chromosome and encodes in a coregulator of the zinc-finger transcription factor THAP11 that affects the expression of the MMACHC gene.[symptoma.com]
Behavior Disorder
  • Psychiatric conditions and behavioral disorders, visual impairment, and peripheral neuropathy have repeatedly been observed in HMMAC patients but no such findings have been made in those suffering from HMMAX.[symptoma.com]
  • disorders Behavioral disturbances Behavioral problems Behavioral/psychiatric abnormalities Behavioural/Psychiatric abnormality Psychiatric disorders Psychiatric disturbances [ more ] 0000708 Gait disturbance Abnormal gait Abnormal walk Impaired gait[rarediseases.info.nih.gov]
Abnormal Behavior
  • Behavioral changes Behavioral disorders Behavioral disturbances Behavioral problems Behavioral/psychiatric abnormalities Behavioural/Psychiatric abnormality Psychiatric disorders Psychiatric disturbances [ more ] 0000708 Gait disturbance Abnormal gait[rarediseases.info.nih.gov]
Peripheral Neuropathy
  • Psychiatric conditions and behavioral disorders, visual impairment, and peripheral neuropathy have repeatedly been observed in HMMAC patients but no such findings have been made in those suffering from HMMAX.[symptoma.com]

Workup

Neurological symptoms are due to diffuse encephalopathy, delayed myelination, and cerebral atrophy, which are conditions that may be verified by means of diagnostic imaging. Hypsarrythmia is a common electroencephalographic finding [1]. These findings are non-specific, though. Analyses of blood and urine samples have to be carried out and provide essential information as to the underlying metabolic disorder [1]:

  • With regard to blood counts, only neutropenia has been reported in HMMAX patients. It should be kept in mind that megaloblastic anemia is the most common finding in those affected by HMMAC, though.Hyperhomocysteinemia, hypomethioninemia, and homocystinuria are common findings in blood chemistry and urine analysis and point at a remethylation disorder. It should be noted, though, that hyperhomocysteinemia is not a constant feature in HMMAX, despite being a hallmark of homocystinuria with methylmalonic acidemia.
  • Methylmalonic acid concentrations in serum and urine samples are elevated, with urine levels being significantly higher than in HMMAC patients.

Still, these results don't allow for a reliable diagnosis of HMMAX since similar findings may be obtained in patients suffering from much more common disorders like vitamin B12 deficiency and folic acid deficiency, and in those with other hereditary diseases [4]. While serum levels of vitamin B12 and folic acid can be assessed easily, the confirmation and differential diagnosis of HMMAX require genetic studies. Because HMMAC is assumed to be the most common inherited error of cobalamin metabolism, it is likely and reasonable that patients are first tested for MMACHC mutations. No such mutations will be detected in case of HMMAX, though. In a second step, complementation studies may be carried out: They will suggest HMMAC despite negative genetic analyses. This is the typical starting point for diagnostic measures aiming at confirming a tentative diagnosis of HMMAX, which is most reliably achieved by identifying the underlying mutation in the HCFC1 gene [1]. Alternatively, a genealogical analysis of familial aggregation may point at a recessive X-linked inheritance of the disease, which should immediately raise suspicion of HMMAX.

Enzyme activity measurements in fibroblasts or lymphocytes constitute an alternative approach to the diagnosis of combined disorders of cobalamin metabolism, but are more cumbersome than genetic studies and don't provide any information as to the specific mutation. Nevertheless, such assays have to be carried out if the aforementioned analyses don't yield conclusive results despite strong suspicion, or if they are not available. Both methionine synthase and methylmalonyl-CoA mutase activities are decreased in case of HMMAX.

Diffuse Encephalopathy
  • Neurological symptoms are due to diffuse encephalopathy, delayed myelination, and cerebral atrophy, which are conditions that may be verified by means of diagnostic imaging. Hypsarrythmia is a common electroencephalographic finding.[symptoma.com]

Treatment

Guidelines for the diagnosis and management of cobalamin-related disorders including HMMAC have recently been published [4]. Since HMMAX-causing HCFC1 mutations result in reduced expression of the MMACHC gene and thus in functional HMMAC, it seems reasonable to follow these guidelines in case of HMMAX. In general, treatment aims at improving clinical features and normalizing hematological and metabolic values:

  • Cobalamin supplementation is the mainstay of therapy. In order to maintain methionine synthase activity, HMMAC patients should receive regular intramuscular injections of hydroxycobalamin. While the drug may also be administered via the subcutaneous or intravenous route, the efficacy of subcutaneous applications seems to be limited and long-term intravenous treatment is inconvenient. Initially, 0.33 mg of hydroxycobalamin should be administered per kg body weight and day. Over the course of the disease, single doses and injection frequencies may be lowered if clinical and laboratory parameters remain stable. In order to prevent irreversible damage to the nervous system, hydroxycobalamin should be administered to all patients presenting symptoms consistent with a remethylation disorder and those who tested positive for hyperhomocysteinemia [4].
  • The administration of folate and betaine has repeatedly been reported to improve disease control in HMMAC patients and is thus recommended as an additional therapeutic measure [6]. Both folate and betaine enhance the conversion of homocysteine to methionine and thus contribute to the reduction of hyperhomocysteinemia. Beyond that, carnitine and methionine supplementation may be considered but data regarding the efficacy of this measure are scarce.
  • Patients should be recommended to avoid protein restriction and circumstances that may induce a catabolic state. Nitrous oxide shouldn't be utilized in these patients either.

Prognosis

At least one boy affected by HMMAX succumbed to the disease and maternal male infant deaths have repeatedly been reported, suggesting that HMMAX is a potentially fatal disorder. Even though data regarding the long-term outcome of HMMAX patients is scarce, assumptions may be made based on data obtained from those affected by HMMAC: Cobalamin supplementation is likely to improve neurological parameters like cognitive performance and motor function if initiated early enough. Notwithstanding, central nervous system damage is largely irreversible and substantial improvements in cerebral atrophy and white matter changes are not to be expected. Therefore, patients who are diagnosed and treated early probably have a much better prognosis than those who are diagnosed after the manifestation of clinical symptoms. In an ideal scenario, affected individuals are diagnosed before birth or identified by means of newborn screening [7]. Still, even adequate therapy may not entirely prevent the development of complications of homocystinuria with methylmalonic acidemia and pre-existing complications may not respond to treatment. Most patients will probably experience some degree of disability over the course of their life [8].

Etiology

HMMAX is caused by mutations in the HCFC1 gene. This gene is located on the long arm of the X chromosome and encodes in a coregulator of the zinc-finger transcription factor THAP11 that affects the expression of the MMACHC gene. In detail, HMMAX-related HCFC1 mutations are associated with severe reductions in MMACHC mRNA and protein and thus give rise to functional HMMAC. It should also be considered that the THAP11-HCFC1 complex may bind to genes MTR and ABCD4, which are involved in the pathogenesis of homocystinuria without methylmalonic aciduria type cblG and homocystinuria with methylmalonic acidemia type cblJ, respectively. Even though MTR and ABCD4 mRNA and protein levels didn't seem to be affected in those HMMAX patients examined by Yu and colleagues, the underexpression of these genes may contribute to the known phenotype of combined methionine synthase and methylmalonyl-CoA mutase deficiency. The high severity of symptoms observed in HMMAX patients may indeed be explained by a global impairment of cobalamin metabolism comparable to combined HMMAC, homocystinuria without methylmalonic aciduria type cblG and homocystinuria with methylmalonic acidemia type cblJ [1]. Interestingly, THAP11 mutations have recently been identified in a patient who presented with clinical and biochemical features overlapping those of HMMAX, but who tested negative for MMACHC and HCFC1 mutations [9].

Of note, mutations in the HCFC1 gene have also been related to X-linked mental retardation type 3 (MRX3). Contrary to HMMAX-related mutations, sequence anomalies identified in MRX3 patients may result in HCFC1 overexpression. Furthermore, additional genetic defects have been detected in some individuals with MRX3 [10]. Further research is required to shed more light on the genetic and possibly non-genetic differences between patients suffering from HMMAX or X-linked mental retardation type 3.

Epidemiology

Inborn errors of cobalamin metabolism are rare diseases, with HMMAC being the most common one. More than 250 cases have been reported to date and the incidence of HMMAC has been estimated to 1-5 in 200,000 life births [3] [11] [12]. It may be assumed that some of these patients, particularly males, may indeed have suffered from HMMAX. There's room for reasonable doubt in all cases that have not been confirmed by genetic studies, which are 14/204 and 3/118 in two studies published by a Canadian research group [11] [13]. The paper published by Yu and colleagues suggests that mutations in the HCFC1 gene are not uncommon in male patients that have been diagnosed with HMMAC: Such mutations have been detected in 13/17 patients who tested negative for MMACHC mutations.

In general, both males and females may be affected by homocystinuria with methylmalonic acidemia. However, recessive X-linked inheritance largely favors males over females. While males who are hemizygous for pathogenic HCFC1 mutations will develop HMMAX, females will not be affected unless they carry two pathogenic alleles.

All HMMAX patients reported to date developed clinical disease within five months of life [1]. By contrast, the onset of HMMAC-associated symptoms may occur at any time between the neonatal period and adulthood [2]. Further research is required to clarify whether there is a late-onset form of HMMAX.

Sex distribution
Age distribution

Pathophysiology

Similar to HMMAC, HMMAX is a combined disorder of cobalamin metabolism, i.e., the underlying mutation interferes with the synthesis of methylcobalamin and adenosylcobalamin, cofactors of methionine synthase and methylmalonyl-CoA mutase [3]. Thus, there are two pathophysiological cascades implicated in neurodegeneration and extraneural disease progression:

  • Under physiological conditions, methionine synthase catalyzes the conversion of homocysteine to methionine. Functional methionine synthase deficiency is thus associated with increased serum and tissue levels of homocysteine. Homocysteine and its metabolic product homocysteic acid possibly exert neurotoxic effects and cause neurological deficits in HMMAX patients. At the same time, methionine concentrations are reduced. Shortage of this essential amino acid may interfere with a variety of biological processes, e.g., the function of rapidly proliferating tissues such as bone marrow or epithelia. Methionine is converted to S-adenosylmethionine, which acts as a methyl group donor. Therefore, deficiencies of methionine result in a lack of S-adenosylmethionine and a decreased methylation capacity [4].
  • Little is known about the contribution of functional methylmalonyl-CoA mutase deficiency to the biochemical and clinical presentation of HMMAX. The enzyme is required for the isomerization of methylmalonyl-CoA to succinyl-CoA, which is an intermediate in the tricarboxylic acid cycle. Methylmalonyl-CoA is synthesized from propionyl-CoA. Accordingly, HMMAX is associated with increased levels of propionyl-CoA and methylmalonyl-CoA, and decreased levels of succinyl-CoA. These conditions may affect a myriad of metabolic processes. Possibly, methylmalonyl-CoA mutase deficiency renders HMMAX patients susceptible to metabolic decompensation [3].

Enhanced oxidative stress due to impaired glutathione metabolism has been proposed as an additional factor in HMMAC pathogenesis [14], so it may be assumed that this is also true for HMMAX. The underlying molecular mechanisms have not yet been clarified, though. It also remains unknown whether methionine synthase or methylmalonyl-CoA mutase fulfill non-enzymatic functions. If this was the case, the dysregulation of the respective processes would constitute another pathogenetic mechanism in HMMAX and related disorders.

Prevention

The prenatal diagnosis of HMMAX is feasible. Mutations in the HCFC1 gene can be identified in nucleic acids isolated from chorionic villi or amniotic fluid samples. Targeted genetic analyses require strong suspicion based on the carrier state of both parents. Most reliable results are obtained if the specific HCFC1 mutations of a child's mother or father are known. If genetic studies cannot be realized or yield inconclusive results, biochemical assays and enzyme activity measurements may be carried out. In this context, increased concentrations of homocysteine and methylmalonic acid in cell-free amniotic fluid indicate the possibility of homocystinuria with methylmalonic acidemia but don't allow for the identification of its type. In particular, the distinction between HMMAC and HMMAX is not possible unless genetic data of the child or their parents are available.

Of note, prenatal therapy via maternal treatment with hydroxycobalamin has yielded promising results in a child affected by HMMAC and may be considered if HMMAX is diagnosed [15].

Summary

According to the conventional classification of homocystinuria with methylmalonic acidemia, there are four types of the disease, namely cblC, cblD, cblF, and cblJ [3]. All of them are induced by functional deficiencies of methionine synthase and methylmalonyl-CoA mutase, and they resemble each other in their clinical and biochemical presentation. The distinction of individual types has long since been based on the results of complementation studies. Because such studies are tedious, they have largely been replaced by molecular genetic analyses. The underlying mutations have been identified for cblC, cblD, cblF, and cblJ and can easily been detected by sequencing genes MMACHC, MMACHD, LMBRD1, and ABCD4, respectively [3] [4]. However, scientist still rely on the results of somatic cell complementation if genetic analyses don't yield conclusive results despite strong suspicion, or if they are not available. Complementation studies are also carried out to prove the causal relation between genotypes and phenotypes [11]. Only recently, it has been pointed out that HMMAC may indeed be caused by mutations not affecting the DNA sequence of the MMACHC gene [1] [11]. Because X-linked inheritance has been shown for this variant of HMMAC, it is now referred to as HMMAX.

Patient Information

The term "homocystinuria" refers an increased excretion of homocystine in the urine. This condition may be due to distinct metabolic disorders associated with elevated serum concentrations of homocysteine, an intermediate amino acid and precursor of methionine. In patients suffering from inherited conditions that interfere with the conversion of homocysteine to methionine, blood and tissue levels of homocysteine are increased while methionine concentrations are below reference ranges.

There are different types of homocystinuria and they differ with regards to hematological and biochemical anomalies. Besides hyperhomocysteinemia and hypomethioninemia, patients may have increased serum levels of methylmalonic acids, which is why "homocystinuria with methylmalonic acidemia" is differentiated from "homocystinuria without methylmalonic aciduria". These differences originate from distinct gene defects, but they aren't reflected in the clinical presentation. Most patients suffering from homocystinuria with methylmalonic acidemia present within the neonatal period or infancy: Their parents may claim feeding difficulties and failure to thrive, and affected children show neurological deficits ranging from cognitive impairment to movement disorders and anomalies of muscle tone. Seizures are also common.

Individuals affected by homocystinuria with methylmalonic acidemia type cblX carry mutations in a gene named HCFC1. Thus, genetic studies can be carried out to confirm the diagnosis. Genetic studies may even be realized before birth if a child's parents are known to be carriers of HCFC1 mutations. Boys will develop the disease if they inherit a pathogenic allele from either their mother or their father; girls will develop the disease only if they inherit pathogenic alleles from both their mother and their father. Therefore, males are much more likely to be affected by methylmalonic acidemia type cblX. Few cases have been described to date and data regarding long-term outcomes are not available, so recommendations regarding diagnosis and treatment are mainly based on experiences with patients suffering from other forms of homocystinuria with methylmalonic acidemia. In this context, it is likely that the patients' prognosis largely depends on the time of diagnosis and initiation of treatment. The earlier an adequate treatment is started, the better the prognosis of the individual patient. Treatment consists in intramuscular injections of hydroxycobalamin and oral supplementation of betaine and folic acid. Lifelong therapy is required in all cases and despite utmost compliance with therapeutic regimens, it may not be possible to prevent all complications. If left untreated, homocystinuria with methylmalonic acidemia type cblX follows a slowly progressive course and may lead to severe disability or death.

References

Article

  1. Yu HC, Sloan JL, Scharer G, et al. An X-linked cobalamin disorder caused by mutations in transcriptional coregulator HCFC1. Am J Hum Genet. 2013; 93(3):506-514.
  2. Huemer M, Scholl-Bürgi S, Hadaya K, et al. Three new cases of late-onset cblC defect and review of the literature illustrating when to consider inborn errors of metabolism beyond infancy. Orphanet J Rare Dis. 2014; 9:161.
  3. Carrillo N, Adams D, Venditti CP. Disorders of Intracellular Cobalamin Metabolism. In: Adam MP, Ardinger HH, Pagon RA, et al., eds. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2017.
  4. Huemer M, Diodato D, Schwahn B, et al. Guidelines for diagnosis and management of the cobalamin-related remethylation disorders cblC, cblD, cblE, cblF, cblG, cblJ and MTHFR deficiency. J Inherit Metab Dis. 2017; 40(1):21-48.
  5. Morath MA, Hörster F, Sauer SW. Renal dysfunction in methylmalonic acidurias: review for the pediatric nephrologist. Pediatr Nephrol. 2013; 28(2):227-235.
  6. Carrillo-Carrasco N, Chandler RJ, Venditti CP. Combined methylmalonic acidemia and homocystinuria, cblC type. I. Clinical presentations, diagnosis and management. J Inherit Metab Dis. 2012; 35(1):91-102.
  7. Huemer M, Kožich V, Rinaldo P, et al. Newborn screening for homocystinurias and methylation disorders: systematic review and proposed guidelines. J Inherit Metab Dis. 2015; 38(6):1007-1019.
  8. Andersson HC, Marble M, Shapira E. Long-term outcome in treated combined methylmalonic acidemia and homocystinemia. Genet Med. 1999; 1(4):146-150.
  9. Quintana AM, Yu HC, Brebner A, et al. Mutations in THAP11 cause an inborn error of cobalamin metabolism and developmental abnormalities. Hum Mol Genet. 2017; 26(15):2838-2849.
  10. Huang L, Jolly LA, Willis-Owen S, et al. A noncoding, regulatory mutation implicates HCFC1 in nonsyndromic intellectual disability. Am J Hum Genet. 2012; 91(4):694-702.
  11. Lerner-Ellis JP, Tirone JC, Pawelek PD, et al. Identification of the gene responsible for methylmalonic aciduria and homocystinuria, cblC type. Nat Genet. 2006; 38(1):93-100.
  12. Weisfeld-Adams JD, Morrissey MA, Kirmse BM, et al. Newborn screening and early biochemical follow-up in combined methylmalonic aciduria and homocystinuria, cblC type, and utility of methionine as a secondary screening analyte. Mol Genet Metab. 2010; 99(2):116-123.
  13. Lerner-Ellis JP, Anastasio N, Liu J, et al. Spectrum of mutations in MMACHC, allelic expression, and evidence for genotype-phenotype correlations. Hum Mutat. 2009; 30(7):1072-1081.
  14. Pastore A, Martinelli D, Piemonte F, et al. Glutathione metabolism in cobalamin deficiency type C (cblC). J Inherit Metab Dis. 2014; 37(1):125-129.
  15. Trefz FK, Scheible D, Frauendienst-Egger G, et al. Successful intrauterine treatment of a patient with cobalamin C defect. Mol Genet Metab Rep. 2016; 6:55-59.

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Last updated: 2019-07-11 19:54