Mohamed S. Rashed

Application of electrospray tandem mass spectrometry to neonatal screening.

For the past 30 years, neonatal screening programs have been performed largely by using the bacterial inhibition assays developed by Dr Robert Guthrie. These programs focused on a small number of diseases such as phenylketonuria and maple syrup urine disease and involved one test for each disease. During the same period many new diseases were discovered, such as organic acidemias and fatty acid oxidation defects, and they presented a diagnostic challenge to biochemical laboratories. Different mass spectrometric approaches have been the main tools for the diagnosis; however, each has its own limitation. Recently, electrospray tandem mass spectrometry (MS/MS) has provided an alternative automated high throughput, specific, and broad-spectrum approach to screening for a relatively large number of disorders, including those covered by bacterial inhibition assays tests. By using specific scan functions, a large number of amino acids and acylcarnitines in blood spots are quantified in 2 minutes analytical time. A new scan function is described here for quantification and screening for argininosuccinic acid in blood spots, which is a key metabolite in the diagnosis of argininosuccinase deficiency. We describe the results of a 3-year tandem MS/MS-based neonatal study that was performed in our newborn population. We screened 27,624 blood spots and identified 20 cases yielding a frequency of 1:1,381. No false-negative cases were identified, but several false-positive cases were eliminated by repeat analysis by MS/MS of blood or by other means. We also used MS/MS analysis of urine or blood either for confirmation of initial positive results or for follow-up of treatment, such as in glutaric acidemia, citrullinemia, argininosuccinase deficiency, and biopterin-dependent phenylketonuria.

In vitro effects of acetaminophen metabolites and analogs on the respiration of mouse liver mitochondria

Acetaminophen, an analgesic and antipyretic, is toxic in overdose to liver and kidney. The effects on mitochondrial respiration of acetaminophen, its less toxic analog, 3-hydroxyacetanilide, and metabolites which arise from these compounds have been investigated. The parent compounds inhibited NADH-linked respiration reversibly, whereas the metabolites inhibit all mitochondrial respiration, apparently in the Complex III region of the respiratory chain. The quinone derivatives, 4-acetamido-o-benzoquinone and 2-acetamido-p-benzoquinone, are the best inhibitors, with the onset of inhibition dependent on active respiration, suggesting interaction of these compounds with oxidized components of the electron transport chain.

S-(N-methylcarbamoyl)glutathione: a reactive S-linked metabolite of methyl isocyanate.

S-(N-methylcarbamoyl)glutathione, a chemically-reactive glutathione conjugate, has been isolated from the bile of rats administered methyl isocyanate and characterized, as its N-benzyloxycarbonyl dimethylester derivative, by tandem mass spectrometry. The ability of this glutathione adduct to donate an N-methylcarbamoyl moiety to the free -SH group of cysteine was evaluated in vitro with the aid of a highly specific thermospray LC/MS assay procedure. The glutathione adduct reacted readily with cysteine in buffered aqueous media (pH 7.4, 37 degrees C) and after 2 hr, 42.5% of the substrate existed in the form of S-(N-methylcarbamoyl)cysteine. The reverse reaction, i.e. between the cysteine adduct and free glutathione, also took place readily under these conditions. It is concluded that conjugation of methyl isocyanate with glutathione in vivo affords a reactive S-linked product which displays the potential to carbamoylate nucleophilic amino acids. The various systemic toxicities associated with exposure of animals or humans to methyl isocyanate could therefore be due to release of the isocyanate from its glutathione conjugate, which thus may serve as a vehicle for the transport of methyl isocyanate in vivo.

Glutaric Aciduria Type II: Observations in Seven Patients With Neonatal- and Late-Onset Disease

The clinical, biochemical, and neuroradiologic findings and clinical follow-up of seven patients with glutaric aciduria type II are reported.Three phenotypes of the disease are encountered: neonatal-onset form with congenital anomalies (two patients) or without congenital anomalies (three patients) and late-onset form (two patients). The neonatal-onset form presents as an overwhelming illness, with severe hypoglycemia and metabolic acidosis leading to rapid death. Frequently it is associated with perinatal energy deprivation, a neonate with low birth weight and prematurity. The late-onset form presents with intermittent episodes of vomiting, hypoglycemia, and acidosis especially after meals rich in fat and/or proteins. All parents are consanguineous and have a first- or second-degree relationship.Initially, in the two phenotypes with neonatal onset and during crisis in the late-onset phenotype, routine laboratory evaluation showed severe metabolic acidosis, with an increased anion gap, hypoglycemia without ketonuria, and disturbed liver function tests. In the majority of patients with neonatal-onset forms, the kidneys, liver, and at times the spleen are enlarged with an increased echogenic pattern; however, no hepatic or renal cysts are detected. Cardiomegaly is observed in most patients. The diagnosis can be easily and rapidly reached through tandem mass spectrometry study of the blood and can further be confirmed by gas chromatography/mass spectrometry analysis of the urine organic acids.In this report, the magnetic resonance imaging/computed tomography brain studies showed brain atrophy, white matter disease, and in one patient, fluid-filled cavities in the periventricular area and putamina. Fluorine-18-labeled 2-fluoro-2-deoxyglucose positron emission tomographic (FDG PET) brain studies in two patients with late-onset disease showed slightly decreased activity in the cerebral cortex in one and in the caudate nuclei in the other. Brain FDG PET scan and magneticresonance spectroscopy were normal in one patient with neonatal-onset disease.All patients were treated with a diet low in fat and protein, oral riboflavin, and carnitine. The results were promising for the late-onset disease. Intravenous carnitine gave rewarding results in one patient with neonatal-onset disease.

Chiral liquid chromatography tandem mass spectrometry in the determination of the configuration of 2-hydroxyglutaric acid in urine.

D-2-Hydroxyglutaric aciduria and L-2-hydroxyglutaric aciduria are two distinct inherited metabolic diseases. The accurate diagnosis of the exact disorder relies on the determination of the configuration of the enantiomers, either D-2-hydroxyglutaric acid or L-2-hydroxyglutaric acid excreted in excess in urine of patients. The enantiomeric chiral separation of 2-hydroxyglutaric acid was achieved using a ristocetin A glycopeptide antibiotic silica gel bonded column. The chiral column was interfaced with a tandem mass spectrometer for the purpose of specifically detecting the eluting 2-hydroxyglutaric acid. Tandem mass spectrometry was employed using an electrospray ion source in the negative ion mode. Three parent-to-daughter transitions under collision-induced dissociation conditions were used to detect only 2-hydroxyglutaric acid. The two forms of the compound were satisfactorily separated with almost baseline resolution at 4.95 and 5.5 min. Three known patients with 2-hydroxyglutaric aciduria were identified to have L-2-hydroxyglutaric aciduria. The method is simple, selective, rapid, and free from interference.

Improved method to determine succinylacetone in dried blood spots for diagnosis of tyrosinemia type 1 using UPLC-MS/MS.

We describe an improved diagnostic method for tyrosinemia type 1 based on quantifying succinylacetone in dried blood spots by ultra-performance liquid chromatography tandem mass spectrometry. Succinylacetone extracted from a single 3/16 inch disk of specimen collection paper containing a dried blood spot was derivatized with dansylhydrazine, separated on an Acquity UPLC BEH C(18) column (2.1 x 50 mm, 1.7 microm) and detected by electrospray ionization tandem mass spectrometry. Succinylacetone derivative eluted at 0.6 min with a complete run time of 1 min. Using a 13C4 labeled succinylacetone as an internal standard, the calibration plot was linear up to 100 micromol/L with a detection limit (S/N = 3) of 0.2 micromol/L. Intra-day (n = 13) and inter-day (n = 10) variations were better than 10%. The cutoff level of succinylacetone in dried blood spots from healthy infants obtained by the current method was 0.63 micromol/L (n = 151). In dried blood spots from patients with established tyrosinemia type 1 (n = 11), concentration of succinylacetone was 6.4-30.8 micromol/L.

The use of mass spectrometry in the study of chemically-reactive drug metabolises. Application of MS/MS and LC/MS to the analysis of glutathione- and related S-linked conjugates of N-methylformamide

The S-(N-methylcarbamoyl) derivatives of glutathione, cysteine and N-acetylcysteine, the S-linked conjugates derived from a reactive metabolite of N-methylformamide (NMF), were studied in mice dosed with an equimolar mixture of NMF and deuterium-labelled NMF. Following preparation of N-benzyloxycarbonyl derivatives in aqueous media, the title conjugates were isolated, purified as their methyl esters and subjected to analysis by fast atom bombardment mass spectrometry (FAB/MS), fast atom bombardment tandem mass spectrometry (FAB/MS/MS) or thermospray liquid chromatography/mass spectrometry (TSP LC/MS). Characteristic isotope clusters in the FAB or TSP mass spectra facilitated recognition of drug metabolites, while constant neutral loss (89 u) and daughter ion scanning tandem mass spectrometry (MS/MS) experiments provided unique structural information on the conjugates of interest. It is concluded that the combined use of stable isotopes, aqueous-phase derivatization and contemporary mass spectrometric techniques represents a powerful approach for the analysis of glutathione adducts and related S-linked conjugates of chemically-reactive drug metabolites.

Infectious complications of propionic acidemia in Saudia Arabia

A retrospective study of 38 patients with propionic acidemia indicates a high frequency of infections; affecting 80% of such patients. The Saudi Arabian population studied is a product of consanguineous marriages, and presents with a severe phenotype. Most microorganisms implicated are unusual, which suggests an underlying immune deficiency. These frequent infections occur despite aggressive treatment with appropriate diets, carnitine and during acute episodes of the disease with metro‐nidazole, which suggests a global effect of the disease on T and B lymphocytes as well as on the bone marrow cells. Any patient with propionic acidemia should be closely followed up for an intercurrent infection in association with acute metabolic decompensation.

Clinical, fluorine-18 labeled 2-fluoro-2-deoxyglucose positron emission tomography of the brain, MR spectroscopy, and therapeutic attempts in methylenetetrahydrofolate reductase deficiency.

The cases of three infants, two Saudi and one Bahraini, with methylenetetrahydrofolate reductase (MTHFR) deficiency are reported. They presented in the neonatal period with lethargy, poor feeding, hypotonia, and frequent apneas. Tandem mass spectrometry (MS/MS) of a blood spot indicated very low methionine level and of urine revealed high homocysteine. The diagnosis was confirmed by demonstrating severe deficiency of MTHFR in the cultured skin fibroblast. All patients were treated with folinic acid, vitamin B12, betaine, and methionine, with good initial response to the therapy. In two patients, the diagnosis was late and their disease was severe, resulting in neurological crippling. However, in the third patient, who was diagnosed and treated early, the current neurological status is normal. In her case, at 1 month of age, the brain FDG PET scan documented very faint cerebral and cerebellar cortical activities. After 5 months of intensive therapy, that included 200-600 mg/kg per day methionine, she had a dramatic clinical and biochemical recovery as well as a parallel improvement in FDG PET. Brain MR spectroscopy indicated normal neuronal glial and myelin markers for her age. We conclude that the functional changes confirmed by the FDG PET study were better correlated with the clinical course of the patient and adequately monitored the response to therapy. This disease warrants early detection through neonatal screening program, since the beneficial effect of early administration of adequate therapy with combined use of betaine and a high dose of methionine is rewarding and may be the treatment of choice for MTHFR deficiency.

Acetaminophen and protein thiol modification.

Acetaminophen (4′-hydroxyacetanilide, APAP) is a widely-used analgesic and antipyretic drug which, while considered to be safe at therapeutic doses, can cause acute hepatic centrilobular necrosis in both humans and experimental animals when consumed in large doses (Boyd and Bereczky, 1966; Prescott et al., 1971; for a review see Hinson, 1980). In a series of classic studies (Mitchell et al., 1973a,b; Jollow et al., 1973, 1974; Potter et al., 1973, 1974), protein thiol group arylation by a reactive quinone imine metabolite of APAP was implicated in the pathogenesis of hepatotoxicity. Indirect evidence to support the hypothesis that cysteinyl thiol groups were arylated was provided by mass spectral characterization of thioether metabolites of acetaminophen (Jollow et al., 1974; Knox and Jurand, 1977; Nelson et al., 1981), and the 3-position of the aromatic ring was determined by 1H and 13C-NMR to be the site of conjugation with glutathione (Hinson et al., 1982). A few years later (Streeter et al., 1984; Hoffman et al., 1985), cysteinyl thioether conjugates at the same position of the aromatic ring were characterized as the major protein bound residues of acetaminophen.