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Xanthinuria

Xanthinuria, the presence of increased quantities of xanthine in the urine, is a genetic disorder characterized by a deficiency of the enzymes involved in purine metabolism, thereby leading to excessive accumulation of xanthine in the body.


Presentation

Xanthinuria is a hereditary disease with two major forms- types I and II. Both forms show an autosomal recessive mode of inheritance and are differentiated by the purine metabolism enzyme that is deficient. The enzyme xanthine dehydrogenase is deficient in type I xanthinuria while a dual deficiency of xanthine dehydrogenase and aldehyde oxidase occurs in type II xanthinuria. The third type of xanthinuria, associated with molybdenum cofactor deficiency, has been described as a separate clinical entity due to the neurological involvement. In addition, iatrogenic xanthinuria may be rarely observed in patients treated with allopurinol during the course of aggressive chemotherapy [1] [2].

There is no difference in the clinical presentations of xanthinuria type I and type II. The enzyme deficiencies which are seen in xanthinuria prevent the transformation of hypoxanthine to xanthine and xanthine to uric acid. There is a salvage pathway for hypoxanthine, while a similar pathway for xanthine does not exist. Consequently, the xanthine accumulates and is excreted in the urine. Furthermore, excessive xanthine accumulates mostly within the kidneys, leading to nephropathy and urolithiasis, making the kidneys more prone to infections. Renal failure is the most severe consequence of xanthinuria [3] [4] [5].

Symptoms in patients with xanthinuria mimic the symptoms seen in any other condition presenting with the stone formation or urinary infection. Renal colic, dysuria, nocturia, polyuria, microscopic or macroscopic hematuria, and pyuria may be commonly observed in such patients.

Other less common sites of xanthine deposits are the muscles and the joints. Myopathy mainly occurs in older patients and results in muscle cramps and pain. The involvement of the joints clinically results in joint pain and stiffness [6].

Non-specific symptoms such as abdominal pain, nausea, vomiting, and irritability may be present in young children. Some pediatric patients may have growth retardation as a consequence of xanthinuria. However, two-thirds of patients may not have any symptoms at all and the disease is revealed accidentally [6] [7].

Recurrent Urinary Tract Infection
  • Some signs and symptoms related may include abdominal pain, recurrent urinary tract infections and hematuria. Less often, xanthine crystals accumulate in the muscles, causing pain and cramps.[ivami.com]
  • Related signs and symptoms can include abdominal pain, recurrent urinary tract infections, and blood in the urine (hematuria). Less commonly, xanthine crystals build up in the muscles, causing pain and cramping.[ghr.nlm.nih.gov]
Colic
  • Renal colic, dysuria, nocturia, polyuria, microscopic or macroscopic hematuria, and pyuria may be commonly observed in such patients. Other less common sites of xanthine deposits are the muscles and the joints.[symptoma.com]
  • Sometimes they might experience the passage of multiple brownish yellow stones with urine. [1] Nausea and vomiting May accompany the ureteric colic. [2] Dysuria, urinary frequency, urine incontinence They may experience pain while passing urine, increased[explainmedicine.com]
  • Around 40% of patients suffer irritability, hematuria, renal colic, crystalluria, acute renal failure or urolithiasis.[cags.org.ae]
  • Approximately 50 % of the patients with classical hereditary xanthinuria present with symptoms of urinary tract infection, hematuria, renal colic, acute renal failure, crystalluria or urolithiasis.[orpha.net]
  • Less than half of the patients have symptoms, which are caused by deposition of xanthine in the urinary tract, resulting in hematuria or renal colic and rarely in acute renal failure or chronic complications related to urolithiasis.[ommbid.mhmedical.com]
Muscle Cramp
  • Myopathy mainly occurs in older patients and results in muscle cramps and pain. The involvement of the joints clinically results in joint pain and stiffness.[symptoma.com]
  • Muscle cramps, muscle pain, muscle stiffness Accumulation of xanthine inside the muscles can cause muscle pathology-"myopathy". [3] This might be aggravated after exercise.[explainmedicine.com]
  • Clinical manifestations of the myopathy (eg, muscle cramps, muscle pain, muscle stiffness) are believed to be the result of long-term accumulation of xanthine and hypoxanthine crystals in the muscle; this has been demonstrated in skeletal muscle biopsies[thehealthscience.com]
Irritability
  • Non-specific symptoms such as abdominal pain, nausea, vomiting, and irritability may be present in young children. Some pediatric patients may have growth retardation as a consequence of xanthinuria.[symptoma.com]
  • Around 40% of patients suffer irritability, hematuria, renal colic, crystalluria, acute renal failure or urolithiasis.[cags.org.ae]
  • Irritation of the tubular epithelium by xanthine crystals results in hematuria, whereas renal tissue deposits induce an inflammatory reaction and consequent interstitial nephritis.[thehealthscience.com]
Suggestibility
  • The determination of the urinary excretion of purine bases in her family demonstrated a slightly increased urinary excretion of oxypurines in her younger brother, suggesting that he was a heterozygote.[ncbi.nlm.nih.gov]
  • Similar findings were observed in at least 6 other relatives, a finding that suggested that they were heterozygotes.[ncbi.nlm.nih.gov]
  • It is suggested that xanthine oxydase may be present in the placenta.[ncbi.nlm.nih.gov]
  • The rise in this ratio suggests that residual xanthine oxidase activity may have been present.[ncbi.nlm.nih.gov]
  • We present the clinical, biochemical, ultrasound and molecular genetics findings in three new patients with HX and suggest a simple three-step approach to be used for diagnosis, typing and confirmation of HX.[ncbi.nlm.nih.gov]
Frequency of Micturition
Nocturia
  • Renal colic, dysuria, nocturia, polyuria, microscopic or macroscopic hematuria, and pyuria may be commonly observed in such patients. Other less common sites of xanthine deposits are the muscles and the joints.[symptoma.com]
Urinary Retention
  • The propositus, a 13-month-old boy, presented with abdominal pain and urinary retention followed by stone passage (0.9x0.6 cm). Infrared spectroscopy in Yerevan revealed a pure xanthine stone.[ncbi.nlm.nih.gov]

Workup

Xanthinuria is a rare cause of renal disease and other more common disorders must be ruled out first. However, if the diagnosis is suspected, it can be confirmed through laboratory and imaging techniques.

Urinalysis may reveal the presence of xanthine crystals along with other findings suggestive of kidney damage such as hematuria and pyuria. The levels of uric acid are extremely low. The 24-hour urine levels of xanthine and hypoxanthine, on the other hand, are significantly high. A urine culture may detect the microorganisms responsible for superadded infection [8].

Changes in serum chemistry are analogous to those seen in the urine. A low serum uric acid, coupled with increased levels of xanthine and hypoxanthine are usually seen. Other causes of a low serum uric acid should be considered while making a diagnosis of xanthinuria.

Imaging studies help support the diagnosis. Ultrasonography may detect stones larger than 1 cm in diameter. Xanthine stones are radiolucent and cannot be revealed via an X-ray. Computed tomography (CT) or magnetic resonance imaging (MRI) scans are recommended for patients presenting with the typical clinical features of nephrolithiasis but with a negative result on ultrasonography [9]. Histology may reveal renal parenchymal xanthine deposits, thereby leading to renal damage and fibrosis.

Nephrolithiasis
  • Computed tomography (CT) or magnetic resonance imaging (MRI) scans are recommended for patients presenting with the typical clinical features of nephrolithiasis but with a negative result on ultrasonography.[symptoma.com]
  • Evidence for enhanced hypoxanthine salvage. ( 3818951 ) Mateos F.A....Fox I.H. 1987 22 Effect of fructose infusion in hereditary xanthinuria. ( 3728145 ) Mateos F.A....Fox I.H. 1986 23 Hereditary xanthinuria presenting in infancy with nephrolithiasis.[malacards.org]
  • Seponering af allopurinol FOREKOMST Meget sjælden. nyresten, urolithiasis, nephrolithiasis, kidney stone, stone analysis, calcium oxalate, uric acid, urinsyre, sten, Kim Hovgaard Andreassen, urolithiasis guide, stenanalyse, årsager til nyresten, cystinuri[urolithiasisguide.dk]
Pyuria
  • Urinalysis may reveal the presence of xanthine crystals along with other findings suggestive of kidney damage such as hematuria and pyuria. The levels of uric acid are extremely low.[symptoma.com]
Hypouricemia
  • Hypouricemia is caused by various diseases and disorders, such as hepatic failure, Fanconi renotubular syndrome, nutritional deficiencies and genetic defects. Genetic defects of the molybdoflavoprotein enzymes induce hypouricemia and xanthinuria.[ncbi.nlm.nih.gov]
  • A 60-year-old Japanese man was diagnosed as having hypouricemia at an annual health check-up.[ncbi.nlm.nih.gov]
  • A 43-year-old xanthinuric female was referred to our department because of hypouricemia.[ncbi.nlm.nih.gov]
  • An 80-year-old man with squamous cell carcinoma of the parotid gland was noted to have persistent severe hypouricemia with serum uric acid values of 0.5 to 1.0 mg/dL.[ncbi.nlm.nih.gov]
  • Xanthinuria due to xanthine dehydrogenase (XDH) deficiency is a rare genetic disorder characterized by hypouricemia and the accumulation of xanthine in the urine.[ncbi.nlm.nih.gov]

Treatment

  • Possible healthcare treatment Options Currently, there is no healthcare treatment available for Xanthinuria . However, there are healthcare treatment and maintenance needed to keep a balance fluid in the body and avoiding high purine foods.[besttreatmenthq.com]
  • Treatment Currently, there is no treatment available for Xanthinuria . However, there are treatment and maintenance needed to keep a balance fluid in the body and avoiding high purine foods.[medigest.uk]
  • The treatment of choice is to increase fluid intake so that the urine xanthine concentration remains below the level at which xanthine crystallizes. This may require adjustment of the urine pH.[ncbi.nlm.nih.gov]
  • Currently, there is no treatment available for Xanthinuria . However, there are treatment & maintenance needed to keep a balance fluid in the body & avoiding high purine foods.[signssymptoms.org]
  • Management and treatment There is no curative treatment. Low purine diet and high fluid intake is recommended. Since the solubility of xanthine is not affected by urinary pH, alkalization is of no value.[orpha.net]

Prognosis

  • Prognosis The overall prognosis is favorable, even though, in some cases, the disease progresses to end-stage renal insufficiency. The documents contained in this web site are presented for information purposes only.[orpha.net]
  • The word "symptoms of Xanthinuria" is the more general meaning; Prognosis - Xanthinuria Not supplied. Treatment - Xanthinuria Not supplied. Resources - Xanthinuria Not supplied.[checkorphan.org]
  • The prognosis for our patient with hereditary type II xanthinuria is excellent, if his renal function can be conserved. 1 Moreover, this child was not hypericosuric but hypouricaemic and hypouricosuric.[jmg.bmj.com]

Etiology

  • As our case and other studies on genetic alterations in kidney diseases show, large deletions (and duplications) significantly contribute to the etiology of these entities, specific assays to discover these imbalances should therefore be included in genetic[ncbi.nlm.nih.gov]
  • Etiology Hereditary xanthinuria is due to mutations in the xanthine dehydrogenase ( XDH , 2p23.1) or molybdenum cofactor sulfurase ( MOCOS , 18q12.2) genes, resulting in failure to degrade hypoxanthine and xanthine to uric acid and leading to the accumulation[orpha.net]

Epidemiology

  • Summary Epidemiology Prevalence of hereditary xanthinuria is not known, but about 150 patients have been described so far. Annual incidence has been estimated to be between 1:6,000 and 1:69,000.[orpha.net]
  • Epidemiology Frequency United StatesTrue incidence of classic xanthinuria is unknown because it is rarely reported. Surveys suggest a population incidence of 1 case per 6,000 population to 1 case per 69,000 population.[thehealthscience.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology The primary organs affected in xanthinuria are the kidney and, to a lesser extent, skeletal muscle and joints.[thehealthscience.com]
  • Xanthine oxidoreductase - Role in human pathophysiology and hereditary xanthinuria. In: Scriver CR, Beaudet AL, Sly WS, Valle D, eds. The metabolic and molecular basis of inherited disease. New York: McGraw Hill, 2001 : 2653 –62.[jmg.bmj.com]

Prevention

  • It is possible that the excessive re-utilization of hypoxanthine and xanthine in this disease prevents the allopurinol-induced inhibition of de novo purine biosynthesis that is seen in normal subjects.[ncbi.nlm.nih.gov]
  • High fluid intake and purine restriction did not prevent further stone passages. The affected asymptomatic sister had a small pelvic stone (4 mm).[ncbi.nlm.nih.gov]
  • Drinking water at night is important to prevent the usual development of a concentrated morning urine. Dehydration prevention: Educate the patient about the importance of preventing dehydration.[emedicine.medscape.com]
  • Mutations in the gene Moços prevent xanthine dehydrogenase and aldehyde oxidase are activated.[ivami.com]
  • The enzyme deficiencies which are seen in xanthinuria prevent the transformation of hypoxanthine to xanthine and xanthine to uric acid. There is a salvage pathway for hypoxanthine, while a similar pathway for xanthine does not exist.[symptoma.com]

References

Article

  1. Dent C, Philpot G. Xanthinuria, an inborn error (or deviation) of metabolism. Lancet.1954;266(6804):182-185.
  2. Ichida K, Matsumura T, Sakuma R, Hosoya T, Nishino T. Mutation of human molybdenum cofactor sulfurase gene is responsible for classical xanthinuria type II. Biochem Biophys Res Commun. 2001;282(5):1194-200.
  3. Simmons A, Reiter S, Nishino T. Hereditary Xanthinuria, in The Metabolic and Molecular Bases of Inherited Diseases, 5. 1995;2:1781–1797.
  4. Ardan T, Kovaceva J, Cejková J. Comparative histochemical and immunohistochemical study on xanthine oxidoreductase/xanthine oxidase in mammalian corneal epithelium. Acta Histochem. 2004;106(1):69-75.
  5. Sperling O, Liberman U, Frank M, De Vries A. Xanthinuria: An additional case with demonstration of xanthine oxidase deficiency. Am J Clin Pathol. 1971;55:351-354.
  6. Yakubov R, Nir V, Kassem E, Klein-Kremer A. Asymptomatic classical hereditary xanthinuria type 1. Harefuah. jun 2012;151(6):330-331.
  7. Sikora P, Pijanowska M, Majewski M. Acute renal failure due to bilateral xanthine urolithiasis in a boy with Lesch-Nyhan syndrome. Pediatr Nephrol.2006;21(7):1045-1047.
  8. Carpenter TO, Lebowitz RL, Nelson D, Bauer S. Hereditary xanthinuria presenting in infancy with nephrolithiasis. J Pediatr. 1986;109(2):307-309.
  9. Mraz M, Hurba O, Bartl J, et al. Modern diagnostic approach to hereditary xanthinuria. Urolithiasis. 2015;43(1):61-67.

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Last updated: 2017-08-09 17:38