P. Kamoun

Endogenous hydrogen sulfide overproduction in Down syndrome

The cystathionine beta synthase (CBS) gene is localized on chromosome 21 (21q22.3). This enzyme is one of three enzymes able to produce hydrogen sulfide. CBS is overexpressed in Down syndrome with levels 166% of normal values in fibroblasts [Chadefaux et al., 1985] and 1,200% in myeloblasts [Taub et al., 1999]. The CBS overexpression could induceanoverproduction ofhydrogen sulfide in Down syndrome patients, and this overproduction is potentially able to induce some of the clinical signs of Down syndrome such as hypotonia and mental retardation. As thiosulfate is the main catabolite of hydrogen sulfide [Kangas and Savolainen, 1987], we compared the levels of this molecule in the urine of Down syndrome patients and control subjects. Human erythrocytes containvarious formsofhemoglobin.These include sulfhemoglobin, which is formed by transformation of the ferric derivative of hemoglobin, methemoglobin. Sulfhemoglobin production requires hydrogen sulfide (or another sulfide) andmethemoglobin [Nichols et al., 1968]. The determination of sulfhemoglobin in erythrocytes was therefore also used to assess hydrogen sulfide production in Down syndrome. Informed consent was obtained from Down syndrome patients and their parents and from controls. The subjects were assigned to three groups. Group 1 (diet-matched pairs) consisted of 21 pairs of subjects (17 of them were included in a previously published study [Belardinelli et al., 2001]. In each volunteer family, one Down syndrome subject and one relative (mother or father in most families, brother or sister in rare cases) were given identical diets. This group consisted of 13 male and 8 female Down syndrome subjects and matched controls (10 male and 11 female). Sulfur compounds were excluded from the daily treatments of Downsyndromepatientsandcontrols.Group2consisted of 30 patients with Down syndrome (19 male and 11 female) and 20 controls (volunteers from the laboratory; 10 male and 10 female). In this group, age distribution was similar for Down syndrome patients and controls (Table I). The first urine produced in the morning was collected from the subjects of groups 1 and 2 in vials containing boric acid used as a preservative. Thiosulfate was determined in urine by colorimetry after chromatographic separation [Voroteliak et al., 1993]. Creatinine was determined by the manual Jaffe method. Group 3 consisted of 60 Down syndrome patients (33 male and 27 female) and 60 age-matched controls (35 male and 25 female). Venous blood was withdrawn in fasting subjects of group 3; erythrocytes were separated by centrifugation and hemolysates were frozen until use. Sulfhemoglobin was determined by spectrophotometry and the results are expressed as ratio of absorbance (A) at various wawelengths: (A622 nm A636 nm)/(A535 nmþA560 nm) 0.5 10. This ratio was used because it is not affected by differences between the respective concentrations of oxygenated and unoxygenated hemoglobin. A significant difference was observed in the urinary excretion of thiosulfate between Down syndrome patients and relatives of group 1 (diet-matched pairs) (Table I). In group 2, statistical analysis indicates that the differences in thiosulfate excretion persisted. To confirm that hydrogen sulfide was overproduced in Down syndrome patients, we studied erythrocyte sulfhemoglobin content in subjects of group 3. The wawelength ratios were 2.51 0.04 and 2.00 0.08 (SEM) for patientswithDownsyndrome and controls, respectively (P<0.001). We obtained two different types of evidence for the overproduction of hydrogen sulfide in Down syndrome patients. The main function of CBS is to catalyze the first step of transsulphuration pathway, producing cysteine from homocysteine. In vivo, the high level of CBS activity in Down syndrome results in low concentrations of the substrate of CBS (homocysteine) in plasma [Chadefaux et al., 1988]. CBS also has another enzymatic activity: the production of hydrogen sulfide from cysteine [Stipanuck and Beck, 1982]. The endogenous productionofhydrogensulfidecanbeestimatedbymonitoring thiosulfate excretion in urine (31 mmoles/day in control adults) [Sorbo and Ohman, 1978]. After hydrogen sulfide poisoning, the excretion of thiosulfate in urine increased significantly [Kangas and Savolainen, *Correspondence to: Pierre Kamoun, Biochimie B–Tour Lavoisier, Hôpital Necker Enfants Malades, 149, rue de Sèvres, 75743 Paris Cedex 15, France. E-mail: pierre.kamoun@nck.ap-hop-paris.fr

Recognition and management of fatty acid oxidation defects: A series of 107 patients

In a personal series of 107 patients, we describe clinical presentations, methods of recognition and therapeutic management of inherited fatty acid oxidation (FAO) defects. As a whole, FAO disorders appear very severe: among the 107 patients, only 57 are still living. Including 47 siblings who died early in infancy, in total 97 patients died, of whom 30% died within the first week of life and 69% before 1 year. Twenty-eight patients presented in the neonatal period with sudden death, heart beat disorders, or neurological distress with various metabolic disturbances. Hepatic presentations were observed in 73% of patients (steatosis, hypoketotic hypoglycaemia, hepatomegaly, Reye syndrome). True hepatic failure was rare (10%); cholestasis was observed in one patient with LCHAD deficiency. Cardiac presentations were observed in 51% of patients: 67% patients presented with cardiomyopathy, mostly hypertrophic, and 47% of patients had heart beat disorders with various conduction abnormalities and arrhythmias responsible for collapse, near-miss and sudden unexpected death. All enzymatic blocks affecting FAO except CPT I and MCAD were found associated with cardiac signs. Muscular signs were observed in 51% of patients (of whom 64% had myalgias or paroxysmal myoglobinuria, and 29% had progressive proximal myopathy). Chronic neurologic presentation was rare, except in LCHAD deficiency (retinitis pigmentosa and peripheral neuropathy). Renal presentation (tubulopathy) and transient renal failure were observed in 27% of patients. The diagnosis of FAO disorders is generally based on the plasma acylcarnitine profile determined by FAB-MS/MS from simple blood spots collected on a Guthrie card. Urinary organic acid profile and total and free plasma carnitine can also be very helpful, mostly in acute attacks. If there is no significant disturbance between attacks, the diagnosis is based upon a long-chain fatty acid loading test, fasting test, and in vitro studies of fatty acid oxidation on fresh lymphocytes or cultured fibroblasts. Treatment includes avoiding fasting or catabolism, suppressing lipolysis, and carnitine supplementation. The long-term dietary therapy aims to prevent periods of fasting and restrict long-chain fatty acid intake with supplementation of medium-chain triglycerides. Despite these therapeutic measures, the long-term prognosis remains uncertain.

Cystathionine β‐synthase mutations in homocystinuria

The major cause of homocystinuria is mutation of the gene encoding the enzyme cystathionine β‐synthase (CBS). Deficiency of CBS activity results in elevated levels of homocysteine as well as methionine in plasma and urine and decreased levels of cystathionine and cysteine. Ninety‐two different disease‐associated mutations have been identified in the CBS gene in 310 examined homocystinuric alleles in more than a dozen laboratories around the world. Most of these mutations are missense, and the vast majority of these are private mutations. The two most frequently encountered of these mutations are the pyridoxine‐responsive I278T and the pyridoxine‐nonresponsive G307S. Mutations due to deaminations of methylcytosines represent 53% of all point substitutions in the coding region of the CBS gene. Hum Mutat 13:362–375, 1999.

Elevated total plasma homocysteine, a risk factor for thrombosis. Relation to coagulation and fibrinolytic parameters

Homocystinuria is a rare inherited metabolic disease. Arterial and venous thromboembolic events represent frequent and life-threatening complications in homocystinuric patients. It has been suggested that mild homocysteinemia could be a risk factor for vascular disease. We have therefore measured total plasma homocysteine (HCy) concentrations by radioisotopic assay in 50 subjects with venous or arterial thrombosis and studied the relationship between HCy, coagulation and fibrinolytic parameters. Values were considered abnormal if they were higher than 2.7 standard deviations (SD) above the mean, i.e., 14.1 mmol/l. Thus, eighteen of the 50 patients with thrombosis were classified in the hyperhomocysteinemia group. Nine of these subjects had only this isolated risk factor. No correlations were found between HCy and antithrombin III, protein C, protein S and plasminogen levels, or plasma plasminogen activator inhibitor activity. Nevertheless, the correlation between tissue-plasminogen activator antigen and total plasma HCy was significant (r = 0.61, p < 0.001). Increased homocysteinemia seems to be a risk factor for thrombotic events especially knowing that HCy presents a direct cytotoxic effect. Vitamin therapy, already used in homozygote homocystinuric patients, might be beneficial in the prevention of thromboembolic disease in heterozygous patients.

Expression of transfected human CuZn superoxide dismutase gene in mouse L cells and NS20Y neuroblastoma cells induces enhancement of glutathione peroxidase activity

The human CuZn superoxide dismutase (superoxide dismutase 1) a key enzyme in the metabolism of oxygen free-radicals, is encoded by a gene located on chromosome 21 in the region 21 q 22.1 known to be involved in Downs syndrome. A gene dosage effect for this enzyme has been reported in trisomy 21. To assess the biological consequences of superoxide dismutase 1 overproduction within cells, the human superoxide dismutase 1 gene and a human superoxide dismutase 1 cDNA were introduced into mouse L cells and NS20Y neuroblastoma cells. Both cell types expressed elevated levels (up to 3-fold) of enzymatically active human superoxide dismutase 1. These human superoxide dismutase 1 overproducers, especially neuronal cell lines, showed an increased activity in the selenodependent glutathione peroxidase. These data are consistent with the possibility that gene dosage of superoxide dismutase 1 contributes to oxygen metabolism modifications previously described in Downs syndrome.

Plasma homocysteine and the extent of atherosclerosis in patients with coronary artery disease

Homocysteine is a graded risk factor for the incidence of stroke and for the degree of carotid atherosclerosis. Homocysteine is also a graded risk factor for the incidence of myocardial infarction but we do not know its precise relations to the severity of atherosclerosis in coronary patients. Seventy five symptomatic coronary patients were recruited for the study. Fifty of these patients had coronary artery disease only and were compared in a case-control manner to 50 healthy controls matched for age and sex. The 25 other coronary patients had also symptoms in another atherosclerotic territory (cerebral, peripheral or both) and were also compared to 25 matched controls. Mean plasma homocysteine level was significantly higher in coronary patients than in controls (11.7 +/- 0.7 mumol l-1, n = 50 versus 9.9 +/- 0.5 mumol l-1, n = 50, p < 0.05). Homocysteine in patients with symptomatic atherosclerosis in two or three arterial sites was 15.7 +/- 1.5 mumol l-1 which differed significantly from matched controls and from patients with coronary artery disease only (p = 0.01). The extent of coronary atherosclerosis evaluated by an angiographic coronary score correlated weakly to plasma homocysteine levels (r = 0.25, p < 0.05). The patients with both hypertension and high levels of homocysteine (> 11.3 mumol l-1, median value) had more severe coronary atherosclerosis (coronary score of 16.3 +/- 2.3 versus 11.9 +/- 0.9, p < 0.05) and more diffuse atherosclerosis (number of atherosclerotic territories of 1.5 +/- 0.2 versus 1.2 +/- 0.7, p = 0.08) than the coronary patients without this association. There were no other high risk association when considering the other classical risk factors. Thus, the highest levels of homocysteine were present in patients with coronary disease and another symptomatic localisation of atherosclerosis. A small gradient in the extent of coronary atherosclerosis was found with increasing levels of homocysteine. The presence of both hypertension and hyperhomocysteinemia was associated with more severe coronary atherosclerosis.

Early alterations of plasma free amino acids in chronic renal failure

In order to assess the influence of renal failure and nutritional status on the fasting concentrations of free plasma amino acids, we studied 81 ambulatory adult patients with varying degrees of chronic renal failure. Each of the patients was in good general and nutritional condition. Compared to 33 healthy controls, patients with mild renal failure (Ccr greater than 25 ml/mn) exhibited significantly (p less than 0.01, Students t test) raised concentrations of cystine, citrulline, ornithine, taurine and 3-methyl-histidine and low level of serine. Concentrations of cystine, citrulline, and 3-methyl-histidine in plasma but not of taurine or ornithine rose in parallel with the progression of renal failure. A significant, but moderate decrease in valine, leucine and isoleucine concentrations was observed in patients with the most marked degree of renal failure (Ccr less than 10 ml/mn). We conclude that changes in the plasma concentration of several non essential amino acids are already present in the early stage of renal failure in patients with no sign of protein malnutrition: these may result from altered metabolic pathways of amino acids related to uremia and/or nephron loss per se whereas the moderate decrease in branched-chain amino acids that is observed only in the advanced stage of renal failure may be, at least in part, nutritional in origin.

Δ1-pyrroline-5-carboxylate synthase deficiency: neurodegeneration, cataracts and connective tissue manifestations combined with hyperammonaemia and reduced ornithine, citrulline, arginine and proline

AbstractΔ1-pyrroline-5-carboxylate synthase (P5CS) catalyses the reduction of glutamate to Δ1-pyrroline-5-carboxylate, a critical step in the biosynthesis of proline, ornithine and arginine. Recently, we reported a newly recognised inborn error due to deficiency of P5CS in two sibs, one presenting at birth with hypotonia, dysmorphic signs, pes planus and clonic seizures. Both developed progressive neurodegeneration and peripheral neuropathy, joint laxity, skin hyperelasticity and bilateral subcapsular cataracts. Their metabolic phenotype includes mild hyperammonaemia, hypo-ornithinaemia, hypocitrullinaemia, hypo-argininaemia and hypoprolinaemia. Incorporation of 3H-proline into protein was deficient in fibroblasts incubated with 3H-glutamate. Both patients are homozygous for the missense mutation R84Q in P5CS. Here, we describe the clinical phenotype of the sibs in detail and show that a relative deficiency of urea cycle intermediates (ornithine, citrulline and arginine) during fasting periods results in a paradoxical hyperammonaemia. Furthermore, we show the results of ornithine loading tests and indirect enzyme studies corroborating the biological significance of the defect in P5CS in vivo. Conclusion:The metabolic phenotype of Δ1-pyrroline-5-carboxylate synthase deficiency is easily missed. The combination of low levels of ornithine, citrulline, arginine and proline plus a tendency to hyperammonaemia or one of the above together with a clinical phenotype of neurodegeneration with peripheral neuropathy and/or cataracts and connective tissue manifestations should suggest this disorder. Early recognition would allow a therapeutic trial with citrulline and proline.

Hyperinsulinism and Hyperammonemia Syndrome: Report of Twelve Unrelated Patients

Hyperinsulinism and hyperammonemia syndrome has been reported as a cause of moderately severe hyperinsulinism with diffuse involvement of the pancreas. The disorder is caused by gain of function mutations in the GLUD1 gene, resulting in a decreased inhibitory effect of guanosine triphosphate on the glutamate dehydrogenase (GDH) enzyme. Twelve unrelated patients (six males, six females) with hyperinsulinism and hyperammonemia syndrome have been investigated. The phenotypes were clinically heterogeneous, with neonatal and infancy-onset hypoglycemia and variable responsiveness to medical (diazoxide) and dietary (leucine-restricted diet) treatment. Hyperammonemia (90–200 μmol/L, normal <50 μmol/L) was constant and not influenced by oral protein, by protein- and leucine-restricted diet, or by sodium benzoate or N-carbamylglutamate administration. The patients had mean basal GDH activity (18.3 ± 0.9 nmol/min/mg protein) not different from controls (17.9 ± 1.8 nmol/min/mg protein) in cultured lymphoblasts. The sensitivity of GDH activity to inhibition by guanosine triphosphate was reduced in all patient lymphoblast cultures (IC50, or concentrations required for 50% inhibition of GDH activity, ranging from 140 to 580 nM, compared with control IC50 value of 83 ± 1.0 nmol/L). The allosteric effect of ADP was within the normal range. The activating effect of leucine on GDH activity varied among the patients, with a significant decrease of sensitivity that was correlated with the negative clinical response to a leucine-restricted diet in plasma glucose levels in four patients. Molecular studies were performed in 11 patients. Heterozygous mutations were localized in the antenna region (four patients in exon 11, two patients in exon 12) as well as in the guanosine triphosphate binding site (two patients in exon 6, two patients in exon 7) of the GLUD1 gene. No mutation has been found in one patient after sequencing the exons 5–13 of the gene.

Methylenetetrahydrofolate Reductase Polymorphism in the Etiology of Down Syndrome

A methylenetetrahydrofolate reductase polymorphism (677 C/T mutation) was recently implicated in the etiology of Down syndrome. We studied a cohort of 85 women carrying fetuses with Down syndrome and found no difference in the frequencies of the three groups of subjects (C/C, C/T, T/T) between Down syndrome mothers and controls.