UNIT 6: Inbor n er r or s of lipid metabolism

Errors in fatty acid metabolism produce numerous genetic disorders. These disorders may be described as 1- fatty oxidation disorders or 2- a lipid storage disorders, and 3- any one of several inborn errors of metabolism that result from enzyme defects affecting the ability of the body to oxidize fatty acids in order to produce energy within muscles, liver, and other cell types. Chapter 18: In Borrn Errors of Fatty Acid Metabolism I)- Classic Refsum Disease : Defective -Oxidation Refsum disease (heredopathia atactica polyneuritiformis) is named for Sigvald Refsum who initially characterized the cardinal clinical features of this disease that results from defects in fatty acid metabolism. Refsums disease is a rare neurologic disorder due to a defect that causes the accumulation of phytanic acid, which is found in plant foodstuffs and blocks oxidation. Specifically, the disorder is due to deficiencies in the peroxisomal enzyme responsible for one of the initial steps in the oxidation of phytanic acid, a 3methyl fatty acid. This enzyme, phytanoyl-CoA hydroxylase (PhyH), carries out an initial oxidation reaction generating the 19-carbon fatty acid, pristanic acid plus CO2. Pristanic acid can then be oxidized by the remainder of the normal fatty acid oxidation pathway, however, these reactions take place within the peroxisomes not the mitochondria. Phytanic acid cannot be synthesized de novo in humans so dietary sources are the exclusive origin of this fatty acid. Dairy products, meat, ruminant fats, and fish are abundant sources of phytanic acid.

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PhyH is localized to the peroxisomes and disorders in peroxisome biogenesis, the peroxisome biogenesis disorders, PBDs (e.g. Zellweger syndrome) manifest with symptoms overlapping with PhyH deficiency.

N.B: The peroxisomes are a single membrane organelle, similar to lysosomes, present in virtually all eukaryotic cells. The peroxisome is a specialized enzyme "factory" that contains in excess of 50 different enzymes involved in a variety of metabolic processes including -oxidation of very long chain fatty acids, oxidation of fatty acids and synthesis of ether-lipids. Proteins that are involved in and necessary for correct peroxisome biogenesis are called peroxins (PEX). The phytanoyl-CoA hydroxylase gene (gene symbol = PHYH or PAHX) resides on chromosome. Deficiencies in PEX7 result in rhizomelic chondrodyplasia punctata, type 1 (RCDP1) which manifests with an associated elevation in phytanic acid due to the inability to properly target PhyH to the peroxisome.
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Clinical Features of Classic Refsum Disease: The important clinical features of Refsum disease are retinitis pigmentosa, chronic polyneuropathy, cerebellar ataxia and elevated protein levels in cerebrospinal fluid. Most cases have electrocardiographic changes, and some have sensorineural hearing loss and/or ichthyosis. Multiple epiphyseal dysplasia (skeletal malformations) is a conspicuous feature in some cases. Refsum disease is a slowly developing, progressive peripheral neuropathy. Progression of the disease results in severe motor weakness and muscle wasting, particularly in the lower extremities. II- Disorders in Mitochondrial -Oxidation: The term fatty acid oxidation disorder (FAOD) is sometimes used, especially when there is an emphasis on the oxidation of the fatty acid. Examples include: Trifunctional protein deficiency, MCADD, LCHADD, and VLCADD, a- Very-Long-Chain Acyl-CoA Dehydrogenase Deficiency - VLCAD Description: Inborn errors of mitochondrial fatty acid beta-oxidation include medium-chain acyl-CoA dehydrogenase deficiency, short-chain acyl-CoA dehydrogenase deficiency, and very long-chain acyl-CoA dehydrogenase deficiency. VLCAD deficiency can be classified clinically into 3 forms: 1- A severe early-onset form with high incidence of cardiomyopathy and high mortality. 2- An intermediate form with childhood onset, usually with hypoketotic hypoglycemia and more favorable outcome; and an adult-onset, 3- Myopathic form with isolated skeletal muscle involvement, rhabdomyolysis, and myoglobinuria after exercise or fasting

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Clinical Features: Total plasma carnitine concentration was low. - Deficiency of the long-chain dehydrogenase in fibroblasts from 2 sibs. Reported deficiency of very long-chain acyl-CoA dehydrogenase in a 2-year old girl with a fatty acid oxidation defect. The infant had hypotonia and marked cardiac enlargement as well as hypoglycemia. Biochemical Features: The pattern of accumulation was characteristic for each disease, making fatty acid analysis of total lipid of postmortem tissues a useful tool in the detection of mitochondrial fatty acid oxidation defects in patients who have died unexpectedly. - Deficiency of 1 of 3 types of acyl-CoA dehydrogenase: medium-chain, very long-chain, and multiple in postmortem. Inheritance: Deficiency of very long-chain acyl-CoA dehydrogenase is an autosomal recessive disorder. Diagnosis: -Organic acid analysis from the urine collected at 12 months of age revealed hypoketotic dicarboxylic aciduria.immunohistochemical technique was an effective diagnostic tool for VLCAD deficiency.

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b- Long-Chain Acyl-CoA Dehydrogenase Deficiency LCAD

Schematic demonstrating mitochondrial fatty acid beta-oxidation and effects of LCHAD deficiency

c- Medium-Chain Acyl-CoA Dehydrogenase Deficiency MCAD Deficiency The acyl-CoA dehydrogenases are a family of enzymes involved in the first step of the mitochondrial -oxidation of fatty acids. Medium-chain acyl-CoA dehydrogenase (MCAD), which is also called acyl-CoA dehydrogenase, medium-chain (ACADM), is so called because of the size range of its fatty acylCoA substrates. MCAD acts on fatty acyl-CoA molecules that range in size from 12 down to 4 carbons in length. Deficiency in MCAD is the most common defect observed in the process of mitochondrial -oxidation of fatty acids. In fact, MCAD deficiency is one of the most common inherited disorders of metabolism occurring with a frequency of approximately 1 in 10,000 live births. This disorder has been described in populations world-wide with the most occurring in individuals of northwestern European origin. MCAD deficiency is a disease that satisfies the criteria for newborn screening and is in fact one of the diseases that is screened for in the US in all newborns.
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MCAD deficiency is a common inherited disorder with a frequency that approaches PKU. The disease can result in life threatening complications and relatively simple dietary intervention can avert the clinical phenotype of MCAD deficiency. The MCAD gene (acyl-CoA dehydrogenase, medium chain: gene symbol = ACADM) resides on chromosome 1p31 spanning 12 exons encoding a 421 amino acid protein. At least 340 mutations in the ACADM gene have been identified. By far, the most prevalent mutation (89%) found in MCAD deficiency patients is a single nucleotide substitution at position 985. This substitution is a A for G change that converts amino acid 329 from a lysine to a glutamic acid (K329E). This mutation alters the -helical domain of the C-terminal portion of the enzyme. In addition to the A985G substitution mutation several additional nucleotide substitution mutants, insertion and deletion mutants have been identified in MCAD deficiency patients.

Clinical Features of MCAD Deficiency: The most common symptom of MCAD deficiency is episodic hypoketotic hypoglycemia brought on by fasting. Symptoms appear within the first 2 years of life. Clinical crisis is characterized by an infant presenting with episodes of vomiting and lethargy that may progress to seizures and ultimately coma. A prior upper respiratory or gastrointestinal viral infection will lead to reduced oral intake in these infants which can precipitate the acute crisis. Autopsy results will often find marked fatty liver (hepatic steatosis) and cerebral edema. These findings are sometimes misdiagnosed as Reye syndrome especially in the circumstance where there is reported a prior infection. Because the capacity of the gluconeogenesis pathway is limited in newborn infants, they are highly susceptible to the lack of brain energy from the ketones that would normally be derived from fatty acid oxidation.

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The defect in fatty acid oxidation leads to the presence, in the plasma and urine, of toxic metabolic intermediates such as dicarboxylic acids. Characteristic and diagnostic of MCAD deficiency is the presence of octanoylcarnitine. Diagnosis can be made within 24 to 48h in specialized laboratories using tandem mass spectrometry (MS) of the blood for specific acylcarnitines. In MCAD deficiency the acylcarnitines that are found are highly diagnostic and specific for this disorder and include C6:0-, 4-cis-, and 5-cis-C8:1, C8:0, and 4cis-C10:1 acylcarnitine species. The primary goal of treatment for MCAD deficiency patients is to provide adequate caloric intake, the avoidance of fasting and IV glucose to treat acute episodes, and aggressive therapy during periods of infection. Anorexia can develop during infections and fever leading to mobilization of stored fatty acids. The effect of increased lipid mobilization is the production of toxic intermediates which can lead to vomiting, lethargy, coma, and even death. Treatment with oral carnitine increases the removal of these toxic intermediates.

MCAD DEFICIENCY :
In summary, Medium-chain fatty acyl CoA dehydrogenase (MCAD) deficiency impairs metabolism of medium chain (C6C12) fatty acids. The C6C12 fatty acids and their esters accumulate in tissues to cause toxicity. Spillover of C6C10 acylcarnitine species into the blood provides for very specific diagnosis of MCAD. Children afflicted with MCAD deficiency experience muscle weakness, lethargy, fasting hypoglycemia, and hyperammonemia, which may lead to seizures, coma and, potentially, brain damage and death. MCAD deficiency is inherited in an autosomal recessive manner with an incidence of 1 in 8500 in the United States.

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 MCAD deficiency is more common than SCAD deficiency, which impairs oxidation of short-chain (< C6) fatty acids, or LCHAD deficiency, which impairs oxidation of long-chain (C12C22) fatty acids. Principal treatments of MCAD deficiency are to avoid fasting (even overnight), to supplement with carnitine, and to manage infections aggressively. d- Short-Chain Acyl-CoA Dehydrogenase Deficiency SCAD Description: SCAD deficiency is an autosomal recessive metabolic disorder of fatty acid beta-oxidation. Clinical features are variable: a severe form of the disorder can cause infantile onset of acidosis and neurologic impairment, whereas some patients develop only myopathy. With the advent of screening for inborn errors of metabolism, patients with putative pathogenic mutations but who remain asymptomatic have also been identified. Clinical Features: Two distinct clinical phenotypes of hereditary short-chain acyl-CoA dehydrogenase deficiency have been identified. One type has been observed in infants with acute acidosis and muscle weakness; the other has been observed in middle-aged patients with chronic myopathy. SCAD deficiency is generalized in the former type and localized to skeletal muscles in the latter. Cases with neonatal onset have a variable phenotype that includes metabolic acidosis, failure to thrive, developmental delay, and seizures, as well as myopathy. There are no episodes of nonketotic hypoglycemia, which are characteristic of medium-chain (MCAD) and very long-chain (VLCAD) acyl dehydrogenase deficiencies. Diagnosis: The definitive diagnostic test for SCAD deficiency is an ETF-linked enzyme assay with butyryl-CoA as a substrate, performed after immunoactivation of MCAD, which has similar activity

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Chapter 19: Disorders in Carnitine-Mediated Transport and Carnitine Uptake

The fatty acids are transported by carnitine to mitochondria and defects in this process are associated with several disorders. They involve the step immediately before oxidation, and are often grouped with the oxidation disorders. 1- Carnitine-acylcarnitine translocase deficiency Clinical outline: Neuro- Fasting-induced coma Seizures Inheritance- Autosomal recessive Lab- Hypoketosis- Hypoglycemia, Hyperammonemia, Carnitine-acylcarnitine translocase deficiency, Cardiac Cardiomyopathy, Bradycardia, Atrioventricular block, Mild ventricular hypertrophy on ECG, Premature ventricular contractions, Ventricular tachycardia, Hypotension, Reduced ejection fraction on echocardiogram Pulmonary- Episodic neonatal apnea, Cardiorespiratory arrest Muscle- Muscle weakness. GI Hepatomegaly, Reduced liver function Description Carnitine-acylcarnitine translocase deficiency is a rare autosomal recessive long-chain fatty acid oxidation disorder. Metabolic consequences include hypoketotic hypoglycemia under fasting conditions, hyperammonemia, elevated creatine kinase and transaminases, dicarboxylic aciduria, very low free carnitine and abnormal acylcarnitine profile with marked elevation of the long-chain acylcarnitines. Clinical features include neurologic abnormalities, cardiomyopathy and arrythmias, skeletal muscle damage, and liver dysfunction. Most patients become symptomatic in the neonatal period with a rapidly progressive deterioration and a high mortality rate. However, presentations at a later age with a milder phenotype have been reported.
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Treatment included peritoneal dialysis with a permanent Tenckof catheter in situ, enteral feeding with high calories, low protein, long-chain fatty acids, medium-chain triglyceride oil, and frequent feedings. 2-Carnitine Palmitoyltransferase I (CPT I) Deficiency: CPT deficiency, hepatic, type IA. Description: The CPT1A gene encodes carnitine palmitoyltransferase IA, a liver enzyme involved in fatty acid oxidation. The carnitine palmitoyltransferase (CPT) enzyme system, in conjunction with acyl-CoA synthetase and carnitine/acylcarnitine translocase, provides the mechanism whereby long-chain fatty acids are transferred from the cytosol to the mitochondrial matrix to undergo -oxidation for energy production. The CPT I isozymes (CPT1A and CPT1B) are located in the mitochondrial outer membrane and are detergent-labile, whereas CPT II is located in the inner mitochondrial membrane and is detergent-stable.

3- Carnitine Palmitoylransferase II (CPT II) Deficiency Description: The CPT2 gene encodes carnitine palmitoyltransferase II, an enzyme that participates in fatty acid oxidation. The carnitine palmitoyl
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transferase enzyme system, in conjunction with acyl-CoA synthetase and carnitine/acylcarnitine translocase, provides the mechanism whereby long-chain fatty acids are transferred from the cytosol to the mitochondrial matrix to undergo beta-oxidation. The CPT I isozymes (CPT1A and CPT1B) are located in the mitochondrial outer membrane and are detergent-labile, whereas CPT II is located in the inner mitochondrial membrane and is detergent-stable Carnitine deficiency leads to myopathy and encephalopathy. Carnitine deficiency leads to impaired carnitine shuttle activity; the resulting decreased LCFA metabolism and accumulation of LCFAs in tissues and wasting of acyl-carnitine in urine can produce cardiomyopathy, skeletal muscle myopathy, encephalopathy, and impaired liver function. There are two recognized types of carnitine deficiency, primary and secondary. Primary carnitine deficiency arises from inherited deficiency of CPT-I or CPT-II, both of which are rare disorders showing autosomal recessive inheritance. CPT-I deficiency produces a fasting hypoglycemia due to impaired liver function as a consequence of the inability to utilize LCFAs as fuel. CPT-II deficiency is more common and mainly manifests as muscle weakness, myoglobinemia, and myoglobinuria upon exercise; severe cases lead to hyperketotic hypoglycemia, hyperammonemia, and death. Both these disorders are treated by avoidance of fasting, dietary restriction of LCFAs, and carnitine supplementation; the objective is to stimulate whatever carnitine shuttle activity is present. Carnitine deficiency may also be secondary to a variety of conditions. Impaired carnitine synthesis due to liver disease. Disorders of _-oxidation. Malnutrition due to consumption of some vegetarian diets.
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Depletion by hemodialysis.Increased demand due to illness, trauma, or pregnancy.

Lipid storage disorder:

Lipid storage disorders (or lipidoses) are a group of inherited metabolic disorders in which harmful amounts of lipids (fats) accumulate in some of the bodys cells and tissues. People with these disorders either do not produce enough of one of the enzymes needed to metabolize lipids or they produce enzymes that do not work properly. Over time, this excessive storage of fats can cause permanent cellular and tissue damage, particularly in the brain, peripheral nervous system, liver, spleen and bone marrow.

Chapter 20: Defects in Cholesterol and Lipoprotein Metabolism:

1- DEFECTIVE LDL RECEPTOR IN FAMILIAL HYPERCHOLESTEROLEMIA

Familial hypercholesterolemia (FH) results from inherited deficiency or mutation of the LDL receptor and consequent impairment of uptake and processing of LDL-cholesterol by the liver. LDL receptor deficiency leads to extreme hypercholesterolemia and its sequelae by two mechanisms. Failure to take up cholesterol bound to LDL particles leads to accumulation and consequent elevation of blood LDL cholesterol. Decreased levels of internalized cholesterol lead to elevated activity of the chief enzyme responsible for endogenous cholesterol synthesis, HMG-CoA reductase, and consequent excessive synthesis of cholesterol.

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 Dramatic elevation of blood LDL-cholesterol levels in FH leads to a high risk of atherosclerosis at an early age due to deposition on the linings of the coronary arteries. FH is transmitted as an autosomal dominant trait, so even heterozygotes (frequency of 1 in 500) for LDL receptor mutations have an increased risk of atherosclerosis. The many different LDL receptor gene mutations that lead to FH can be classified into five groups according to the functional defect in the receptor: Null alleles that produce no detectable LDL receptor protein. Mutant receptors that become blocked during processing in the endoplasmic reticulum or Golgi apparatus and thus never reach the plasma membrane. Mutant receptors that cannot bind LDL. Mutant receptors that bind LDL at the cell surface but are blocked in endocytosis and thus do not internalize LDL. LDL receptor mutants that fail to release bound LDL and do not recycle to the cell surface after internalization.

2- Hyperlipoproteinemias:
Disorder Type I (familial LPL deficiency, familial hyperchylomicronemia) Defect (a) deficiency of LPL; (b) production of abnormal LPL; (c) apoC-II deficiency
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Comments slow chylomicron clearance, reduced LDL and HDL levels; treated by low fat/complex carbohydrate diet; no increased risk

Familial hypercholesterolemia, FH Type IIA hyperlipoproteinemia Type III (familial dysbetalipoproteinemia, remnant removal disease, broad beta disease, apolipoprotein E deficiency) Type IV (familial hypertriacylglycerolemia) Type V familial Familial hyper lipoproteinemia. Type II hyperlipoproteinemia Type II Familial hyperbetalipoproteinemia Familial ligand-defective apoB

of coronary artery disease 4 classes of LDL receptor reduced LDL clearance leads to defect hypercholesterolemia, resulting in athersclerosis and coronary artery disease hepatic remnant clearance causes xanthomas, hypercholesteroimpaired due to apoE lemia and athersclerosis in periphabnormality; patients only express eral and coronary arteries due to apoE2 isoform that interacts elevated chylomicrons and VLDLs
poorly with apoE receptor

elevated production of VLDL associated with glucose intolerance and hyperinsulinemia elevated chylomicrons and VLDLs due to unknown cause increased level of HDLs increased LDL production and delayed clearance of triacylglycerols and fatty acids 2 different mutations: Gln for Arg (amino acid 3500) or Cys for Arg (amino acid 3531); both lead to reduced affinity of LDL for LDL receptor absence of LCAT leads to inability of HDLs to take up cholesterol (reverse cholesterol transport) defect in lysosomal cholesteryl ester hydrolase; affects metabolism of LDLs deficiency of the lipase leads to accumulation of triacylglycerol -rich HDLs and VLDL remnants (IDLs)

frequently associated with type-II NIDD, obesity, alcoholism or administration of progestational hormones; elevated cholesterol as a result of increased VLDLs

hypertriacylglycerolemia and hypercholesterolemia with decreased LDLs and HDLs a rare condition that is beneficial for health and longevity strongly associated with increased risk of coronary artery disease dramatic increase in LDL levels; no affect on HDL, VLDL or plasma triglyceride levels; significant cause of hypercholesterolemia and premature coronary artery disease
decreased levels of plasma cholesteryl esters and lysolecithin; abnormal LDLs (Lp-X) and VLDLs; diffuse corneal opacities, target cell hemolytic anemia, and proteinuria with renal failure

Familial LCAT deficiency Norum disease Fish-eye disease Wolman disease (cholesteryl ester storage disease) heparin-releasable hepatic triglyceride lipase deficiency

reduced LDL clearance leads to hypercholesterolemia, resulting in athersclerosis and coronary disease causes xanthomas and coronary artery disease

3- Hypolipoproteinemias:
Disorder Abetalipoproteinemia (acanthocytosis, BassenKornzweig syndrome) Defect Comments no chylomicrons, VLDLs rare defect; intestine and liver or LDLs due to defect in accumulate, malabsorption of fat, apoB expression retinitis pigmentosa, ataxic neuropathic disease, erythrocytes
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Familial hypobetalipoproteinemia

Tangier disease

at least 20 different apoB gene mutations identified, LDL concentrations 10-20% of normal, VLDL slightly lower, HDL normal reduced HDL concentrations, no effect on chylomicron or VLDL production

have thorny appearance mild or no pathological changes

tendency to hypertriacylglycerolemia; some elevation in VLDLs; hypertrophic tonsils with orange appearance

4- Niemann-Pick Diseases
The Niemann-Pick (NP) diseases belong to a family of disorders identified as lysosomal storage diseases. There are two distinct sub-families of NP diseases. NP type A (NPA) and type B (NPB) diseases are caused by defects in the acid sphingomyelinase gene (ASM). NP type C (NPC) diseases are caused by defects in a gene involved in LDL-cholesterol homeostasis identified as the NPC1 gene.

Both Niemann-Pick disease type A and type B are caused by defects in the lysosomal hydrolase, acid sphingomyelinase, ASMase (gene symbol SMPD1, sphingomyelin phosphodiesterase-1). The SMPD1 gene is located on chromosome 11p15.1p15.4 spanning 5 kb and composed of 6 exons encoding a 629 amino acid glycoprotein.
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At least 18 mutations have been identified in the SMPD1 gene resulting in types A and B NP disease. There are three disease alleles that represent greater than 90% of the cases of type A NP disease in Ashkenazi Jewish populations. These disease alleles include a single nucleotide deletion resulting in a frameshift at proline 330 (fsP330) and two different missense mutations, one leading to the substitution of leucine for proline at amino acid 302 (L302P) and the other leading to substitution of arginine for leucine at amino acid 496 (R496L). The carrier allele frequency for this type A mutations is as high as 1 in 80 in Ashkenazi Jewish populations. A single mutation, a 3-base deletion leading to loss of arginine at what would be amino acid position 608 (R608), is commonly associated with type B NP disease. This latter mutation leaves the ASMase protein with sufficient residual activity to afford protection from the severe neurological symptoms associated with type A NP disease. Type A NP disease is associated with a rapidly progressing neurodegeneration leading to death by 2 to 3 years of age. In contrast, type B NP disease has a variable phenotype marked primarily by visceral involvement with little to no neurological detriment. Diagnosis of type B NP disease is usually made in early childhood by the presence of hepatosplenomegaly. The most severely affected type B patients exhibit a progressive pulmonary involvement. Both type A and type B NP disease are characterized by the presence of the "Niemann-Pick" cell. This histologically distinct cell type is of the monocyte-macrophage lineage and is a characteristic lipid-laden foam cell. The course of type A NP disease is rapid. Infants are born following a typically normal pregnancy and delivery. Within 46 months the abdomen protrudes and hepatosplenomegaly will be diagnosed. The early neurological manifestations include hypotonia, muscular weakness and difficulty feeding. As a consequence of the feeding difficulties and the swollen spleen, infants will exhibit a decrease in growth and body weight. By the time afflicted infants reach 6 months of age the signs of psycho-motor deterioration become evident. The infant becomes weaker and progressively hypotonic. Previous developmental milestones such as sitting alone begin to be lost. Ophthalmic examination reveals a cherry-red spot typical of patients with TaySachs disease (another lysosomal storage disease) in about 50% of type A NP disease infants. As the disease progresses spasticity and rigidity increase and infant experience complete loss of contact with their environment.
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As indicated above, type B NP disease has a much more variable phenotype and most patients do not have neurological involvement and are intellectually normal. There is currently no therapy for either type A or type B NP disease.

Niemann-Pick Disease, Type C (NPC):

NPC results from an error in the trafficking of exogenous cholesterol, thus it is more commonly referred to as a lipid trafficking disorder even though it belongs to the family of lysosomal storage diseases. The principle biochemical defect in patients with NPC is an accumulation of cholesterol, sphingolipids, and other lipids in the late endosomes/lysosomes (LE/L) of all cells. NPC is a disease characterized by fatal progressive neurodegeneration. The gene, whose mutations lead to NPC is identified as NPC1 and is located on chromosome 18q11q12 spanning 47 kb and composed of 25 exons. To date more than 200 mutations in the NPC1 gene have been identified in NPC afflicted individuals. The most prevalent mutations are point mutations and many afflicted individuals are genotypic compound heterozygotes harboring at least two of the mutations. The eight most common point mutations identified are at nucleotides: Several additional point mutations have been identified in the NPC1 gene but they do not manifest with disease. The NPC1 gene encodes a 1278 amino acid protein that contains regions of homology to mediators of cholesterol homeostasis suggesting why LDLcholesterol accumulates in lysosomes of afflicted individuals. Within the protein are regions of homology to the transmembrane domain of the morphogen receptor patched (of Drosophila melanogaster) and the sterolsensing domains (SSDs) of SCAP (SREBP cleavage-activating protein; SREBP=sterol regulated element biding protein) and HMG-CoA reductase (HMGR). The NPC1 encoded protein is an integral membrane protein containing 13 putative transmembrane domains. The protein is primarily associated with intralumenal vesicles and multi-vesicular late endosomes. The transmembrane regions of NPC1 are separated by three lumenal loops that contain sites of
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glycosylation. NPC1 also transiently cycles through the trans-Golgi network. The SSD of NPC1 is composed of 5 of the 13 transmembrane domains. At least 95% of NPC patients contain mutations in the NPC1 locus with the remainder harboring mutations in a second gene identified as NPC2. The NPC2 locus is located on chromosome 14q24.3 spanning 13.5 kb and composed of 5 exons encoding a lysosomal glycoprotein of 151 amino acids. The NPC2 protein was originally identified as epididymal secretory protein (HE1). Like the protein encoded by the NPC1 locus, the NPC2 gene product also binds cholesteryl esters. However, unlike NPC1, NPC2 does not bind oxysterols. The NPC2 protein is a soluble protein found in the lumen of lysosomes. The NPC2 protein is targeted to the lysosomes by binding the mannose-6-phosphate receptor. The NPC2 protein is involved in cholesterol movement out of LE/L in conjunction with NPC1. One model proposed for the combined actions of NPC1 and NPC2 is that membrane bound NPC1 interacts with cholesterol that has accumulated in intralumenal vesicle membranes and then transfers the cholesterol to soluble NPC2. The action of NPC2 is then to transfer the cholesterol to the limiting membranes of LE/L which allows for cholesterol distribution to other cellular membranes. An alternative model proposes that NPC2 removes cholesterol from intralumenal vesicles of LE/L and then transfers the cholesterol to NPC1 in the limiting membranes of the LE/L. A gene related to the NPC1 gene is called Niemann-Pick type C1-like 1 (NPC1L1). This gene is expressed in the brush border cells of the small intestine and is involved in intestinal absorption of cholesterol. The cholesterol lowering action of the drug ezemitibe (Zetia) stems from the fact that the drug binds to and interferes with the cholesterol absorption functions of NPC1L1. NPC1L1 is also highly expressed in human liver. A genetic isolate of NP disease first identified in patients in Colorado and Nova Scotia, Canada was originally called NP type D (NPD) disease. However, these patients are now known to have harbored specific alleles of the NPC1 locus. The prevalence of NPC disease is more common than NPA and NPB disease combined, however, as indicated above for NPA, certain ethnic groups have significant disease allele carrier frequency.
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Most afflicted individuals have progressive neurological disease with early lethality. The characteristic phenotypes associated with "classic" NPC disease are variable hepatosplenomegaly, progressive ataxia, dystonia, dementia and vertical supranuclear gaze palsy (VSGP). Like NPA and NPB disease, NPC pathology is characterized by the presence of lipid-laden foam cells in the visceral organs and the nervous system. There is currently no specific treatment for NPC disease.

Chapter 21: Peroxisomal Disorders

Peroxisomes are single-membrane subcellular organelles, similar to lysosomes present in most eukaryotic cells and organisms. The peroxisome is a specialized enzyme "factory" that contains in excess of 50 different enzymes involved in variuos metabolic functions in lipid metabolism, both catabolic (oxidation of pipecolic, phytanic -oxidation of very long chain fatty acids and -oxidation of fatty acids) and anabolic. Fatal disorders are related to defective peroxisomal function or biogenesis. Many oxygen-dependent reactions take place in the peroxisomes to protect the cell against oxygen radicals; the produced H2O2 is metabolised by a catalase. Proteins that are involved in and necessary for correct peroxisome biogenesis are called peroxins (PEX). At least 15 PEX genes have been identified in humans. Enzymes that are targeted to the peroxisomes contain either of two amino acid consensus elements called peroxisome targeting sequences (PTS).

- Defects in Peroxisome Biogenesis:

ZELLWEGER SYNDROME is also known as cerebrohepatorenal syndrome. Zellweger syndrome is a lipid storage disorder caused by impaired peroxisome biogenesis due to deficiency or functional defect of one of eleven proteins involved in the complex mechanism of peroxisomal matrix protein import and assembly of the organelle. These defects suppress many peroxisomal functions, including impaired oxidation of VLCFAs.
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 One of the genes responsible for this disorder, PEX5, encodes the import receptor itself. The cells have absent or undersized peroxisomes with accumulation of VLCFAs, which is especially marked in the liver, kidneys, and nervous tissue. Patients exhibit a broad spectrum of abnormalities, including liver and kidney dysfunction with hepatomegaly, high levels of copper and iron in the blood, severe neurologic defects, and skeletal malformations. Such patients have a high incidence of perinatal mortality and rarely survive beyond 1 year. The condition is of variable severity, but most forms are inherited in an autosomal recessive manner.

There are two genetically determined disorders that manifest with adrenoleukodystrophy (malfunction in the adrenal cortex and nervous system myelin). X-ALD is one and neonatal adrenoleukodystrophy (NALD) is the other. X-linked adrenoleukodystrophy (X-ALD) is a disorder that is a member of a family of disorders that result from defects in the biogenesis and/or functioning of the peroxisomes and are referred to as peroxisome biogenesis disorders, PBDs.

X-LINKED ADRENOLEUKODYSTROPHY: (X-ALD) X-linked adrenoleukodystrophy (X-ALD) is a progressive, inherited neurologic disorder arising from a defect in peroxisomal VLCFA oxidation. The gene for X-ALD encodes a peroxisomal membrane protein whose function is required for VLCFA oxidation, so VLCFAs accumulate in tissues and spill over into plasma and urine. X-ALD is rare, with an incidence of 1 in 20,00040,000. Symptoms arise in boys at about 48 years of age, manifested initially as dementia accompanied in most cases by adrenal insufficiency.
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 The most severely affected patients may end up in a persistent vegetative state. In some patients, milder symptoms develop, starting in the second decade, and include progressive paraparesis (weakness) in the lower extremities. MRI indicates a severe reduction in cerebral myelin, which likely accounts for the central neuropathy. VLCFAs arise from both dietary and endogenous synthetic sources, so treatment is mainly supportive. Feeding a 4:1 mixture of glyceryl trioleate and glyceryl trierucate (Lorenzos Oil) can reduce plasma VLCFA levels, but it is unclear whether this treatment can reverse demyelination. Lovastatin and 4-phenylbutyrate are being tested as new therapeutic approaches to stimulate VLCFA metabolism. Metabolic defect: 1- Both adrenoleukodystrophies are biochemically characterized by the accumulation of very long-chain fatty acids (VLCFAs). 2- X-linked adrenoleukodystrophy is caused by deficiency in the ATP-binding cassette, subfamily D, member 1 gene (symbol ABCD1) located on the X chromosome. The ABCD1 protein is involved in the import and/or anchoring of very long-chain fatty acid-CoA synthetase (VLCFA-CoA synthetase) to the peroxisomes. Clinical Features of X-ALD: - X-ALD is also sometimes called Addison disease which refers to the adrenal deficit. X-ALD results from the accumulation of the saturated very long chain fatty acids (VLCFA) in all tissues of the body, particularly hexacosanic acid (C26:0). -The manifestations of the disorder occur primarily in the adrenal cortex, the myelin of the central nervous system, and the Leydig cells of the testes.

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Incidence : X-ALD in males is estimated to be between 1:20,000 and 1:50,000 live births. Several clinically distinct phenotypes are observed in X-ALD. About 35% of X-ALD patients have the childhood cerebral form in which afflicted boys develop normally until 4 to 8 years of age and then manifest dementia and progressive neurological decline resulting in a vegetative state. Over 90% of these patients have adrenal insufficiency. Approximately 40% of X-ALD patients will present with symptoms in young adulthood which include slowly progressive paraparesis (weakness in the lower extremeties) referred to as adrenomyeloneuropathy. Like the childhood cerebral form of X-ALD, these latter patients also manifest with adrenal insufficiency, observed in about 70% of patients. The remainder of X-ALD cases are rarer manifesting forms such as "Addison-only", adult cerebral, and olivo-ponto-cerebellar. Some female heterozygotes, approximately 20%, develop overt manifestations that resemble the adrenomyeloneuropathy seen in males. Adrenal hormone replacement can alleviate the adrenal insufficiency in X-ALD but does nothing to counter the neurological deficits.

- Neonatal Adrenoleukodystophy (NALD)

Neonatal adrenoleukodystrophy (NALD) is a disorder that is a member of a family of disorders that result from defects in the biogenesis and/or functioning of the peroxisomes and are referred to as peroxisome biogenesis disorders, PBDs. NALD is an autosomal recessive disorder and belongs to the Zellweger spectrum PBDs which includes Zellweger syndrome and infantile Refsum disease (IRD). Zellweger syndrome represents the extreme of the clinical manifestation of peroxisome biogenesis dysfunction with patients rarely surviving their first year of life. Zellweger syndrome is associated with either severe, moderate or mild defects in all peroxisome functions.

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An additional phenotypic spectrum in PBDs is represented by rhizomelic chondrodysplasia punctata, RCDP. RCDP is distinguished from the Zellweger spectrum PBDs by manifesting with more severe skeletal involvement as well as specific biochemical characteristics. NALD can result from mutations in several genes involved in peroxisome biogenesis (PEX genes encoding proteins termed peroxins). These include the PEX1 gene on chromosome 7q21q22, the PEX5 gene on chromosome12p13.3. The PEX1 gene encodes a protein that is a member of the AAA-type ATPases (AAA = ATPases associated with diverse cellular activities). The protein encoded by the PEX13 gene is an integral membrane protein that interacts with the PEX5 encoded PTS1 receptor. The PEX26 encoded protein interacts with the PEX6 encoded protein and may have catalase activity. Clinical Features of NALD: NALD bears many clinical and biochemical similarities to X-linked adrenoleukodystrophy (X-ALD) and Zellweger syndrome including the accumulation of very long chain fatty acids (VLCFA), particularly hexacosanoic acid (C26:0). Given that NALD is inherited as an autosomal recessive disorder and X-ALD is an X-linked disorder it is easy to distinguish these two disorders based upon inheritance patterns. However, biochemically they are distinguishable as well given that NALD results in the accumulation of VLCFAs as a result of defects in numerous peroxisomal enzymes necessary for peroxisomal -oxidation and X-ALD is due to a defect in only the initial step of peroxisomal VLCFA -oxidation. In addition, NALD patients elevated levels of intermediates in bile acid synthesis and elevated plasma levels of pipecolic acid (piperidine-2-carboxylic acid). Fibroblasts isolated from NALD patients are impaired in their ability to oxidize phytanic acid and to synthesize plasmalogens.

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 The clinical course of NALD can be quite rapid and is associated with no psychomotor progression followed by death within several months after birth. Alternatively, some patients have a less severe involvement and survive into their mid teens. However, these latter patients are severely retarded with sensorineural deafness and are blind due to retinopathy. The mental age of surviving NALD patients never exceeds that of a 10 to 12 month old and developmental regression will appear at around 3 to 5 years of age due to the onset of leukodystrophy. - Rhizomelic Chondrodysplasia Punctata, type 1, (RCDP1): Rhizomelic chondrodysplasia punctata, type 1 (RCDP1) is a disorder that is a member of a family of disorders that result from defects in the biogenesis and/or functioning of the peroxisomes and are referred to as peroxisome biogenesis disorders, PBDs. The term "chondrodyplasia punctata" refers to the stippled foci of calcifications in the cartilage. Rhizomelia refers to the hip and shoulder joints and is reflected by a disproportion in the length of the proximal limb. The PBDs are divided into two clinical spectra which includes RCDP and the Zellweger spectrum PBDs. The Zellweger spectrum PBDs includes Zellweger syndrome, infantile Refsum disease (IRD), and neonatal adrenoleukodystrophy (NALD). Zellweger syndrome represents the extreme of the clinical manifestation of PBDs with patients rarely surviving their first year of life. Zellweger syndrome is associated with severe, moderate or mild defects in all peroxisome functions. RCDP1 is distinguished from the Zellweger spectrum PBDs by manifesting with more severe skeletal involvement as well as specific biochemical characteristics as described below. RCDP1 results from mutations in the PEX7 gene that is involved in peroxisome biogenesis (PEX genes encoding proteins termed peroxins). The PEX7 gene is located on chromosome 6q22q24 spanning 102 kb and composed of 10 exons. As discussed below, the PEX7 encoded protein is the receptor for proteins containing a type-2 peroxisomal targeting sequence, PTS2.
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 There are two additional disorders with clinical features of RCDP1 called rhizomelic chondrodysplasia type 2 (RCDP2) and type 3 (RCDP3). Although the morphologicall characteristic of RCDP2 are similar to RCDP1, RCDP2 does not manifest with the biochemical abnormalities of RCDP1. RCDP2 results from defects in the gene encoding dihydroxyacetone phosphate acyltransferase (DHAPAT). The DHAPAT gene (symbol GNPAT for glyceronephosphate O-acyltransferase) is found on chromosome 1q42 and encodes a 680 amino acid protein which contains a PTS1 motif. DHAPAT is a peroxisomal enzyme carrying out one of two pathways in the synthesis of phosphatidic acid (Lipid Synthesis) whose product can be diverted to the ether lipid (the plasmalogens) biosynthesis pathway which occurs in peroxisomes. RCDP3 results from defects in the gene encoding alkyldihydroxyacetone phosphate acyltransferase (alkyl-DHAP synthase). The alkyl-DHAP synthase gene (symbol AGPS for alkylglycerone phosphate synthase) is located on chromosome 2q31 and encodes a 658 amino acid protein which contains a PTS2 motif. Alkyl-DHAP synthase introduces the ether linkage in plasmalogens. Clinical Features of RCDP1: As the name of the syndrome implies, RCDP1 patients have a striking shortening of their proximal limbs which is due to a severe disruption in endochondral bone formation. RCDP is a rare, multisystem, developmental disorder characterized by the presence of stippled foci in the epiphyses especially in the knees, hips, shoulders and elbows. Additional dysmorphic alterations include coronal vertebral clefting, flat nasal bridge, frontal bossing, dwarfing, and joint contractures. Cataracts are present in about 75% of cases, and skin changes in about 30%. Biochemically, RCDP patients have subnormal levels of red cell plasmalogens and progressive accumulation of phytanic acid starting from normal at birth and increasing to levels more than 10 times normal by age 1 year.

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 There are several disorders that are associated with punctate cartilaginous changes such as in some forms of Zellweger syndrome. Thus, care must be taken when attempting a definitive diagnosis of RCDP. The association of punctate calcifications with rhizomelia, red blood cells deficient in plasmalogens, and accumulation of phytanic acid would be a strong indication of RCDP. RCDP patients have severe psychomotor retardation and most do not survive beyond two years of age.

- Infantile Refsum Disease (IRD):

Infantile Refsum disease (IRD) is a disorder that is a member of a family of disorders that result from defects in the biogenesis and/or functioning of the peroxisomes. An additional phenotypic spectrum in PBDs is represented by rhizomelic chondrodysplasia punctata, RCDP. RCDP is distinguished from the Zellweger spectrum PBDs by manifesting with more severe skeletal involvement as well as specific biochemical characteristics. Infantile Refsum disease can result from mutations in at least three genes involved in peroxisome biogenesis (PEX genes). These include the PEX1 gene on chromosome 7q21q22, the PEX2 gene on chromosome 8q21.1, and the PEX26 gene on chromosome 22q11.21. The PEX2 gene is also known as the peroxisomal membrane protein 3 (PXMP3 or PMP35).

Clinical Features of Infantile Refsum Disease: Infantile Refsum disease is so called because patients manifest a form of phytanic acid storage disease that is both clinically and biochemically distinct from patients with the classic form of Refsum disease. The clinical manifestations of IRD include early onset, mental retardation, minor facial dysmorphism, retinitis pigmentosa, sensorineural hearing deficit, hepatomegaly, osteoporosis, failure to thrive, and hypocholesterolemia.

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 The biochemical abnormalities are not restricted to phytanic acid but also include accumulation of very long chain fatty acids (VLCFA), di- and trihydroxycholestanoic acid and pipecolic acid. The retinitis pimentosa, elevated phytanic acid, and sensorineural hearing loss are symptoms seen in classic Refsum disease, but the dysmorphia observed in IRD is unique to the latter disorder. Most patients with IRD will learn to walk but with a gait that is ataxic and wide. Cognitive impairment in IRD is in the severe retarded range.

UNIT 7: Disorders of Isoprenoids and Sterols Metabolism:

Isoprenoids and sterols are essential in many cellular and developmental processes. Most defects of their synthesis are caused by enzyme deficiencies in the postsqualene portion of the pathway. Only mevalonic aciduria and hyperimmunoglobulinemia D syndrome, both due to

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mevalonate kinase deficiency, are found in the proximal part of the pathway. Mevalonate kinase deficiency is the only known defect of isoprenoid biosynthesis. It causes dysmorphic features, failure to thrive, mental retardation, and recurrent febrile crises. An attenuated variant causes hyper-IgD syndrome. Treatment is symptomatic. Defects of sterol biosynthesis cause various structural abnormalities including the dysmorphic features of the Smith LemliOpitz syndrome and mental retardation. Diagnosis involves plasma sterol analysis. In SmithLemliOpitz syndrome, specific treatment by cholesterol supplementation has been of limited success.

Chapter 22:Defects

in Hormone Biogenesis or Function

Congenital Adrenal Hyperplasias, CAH The congenital adrenal hyperplasias (CAH) are a group of inherited disorders that result from loss of function mutations in one of several genes involved in adrenal steroid hormone synthesis. In the virilizing forms of CAH the mutations result in impairment of cortisol production and the consequent accumulation of steroid intermediates proximal to the defective enzyme. In the virilizing forms of CAH there is increased ACTH secretion which leads to elevated synthesis of adrenal androgens. In addition, there is adrenal cortical hyperplasia, the symptom that imparts the name to these disorders. All forms of CAH are inherited in an autosomal recessive manner.

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There are two common and at least three rare forms of virilizing CAH. The common forms are caused by defects in either CYP21A2 (21-hydroxylase, also identified as just CYP21 or CYP21B) or CYP11B1 (11-hydroxylase) (Figure). The majority of CAH cases (90-95%) are the result of defects in CYP21A2 with a incidence of between 1 in 5,000 and 1 in 10,000. Three rare forms of virilizing CAH result from either defects in 3-hydroxysteroid dehydrogenase (HSD3B2), placental aromatase (CYP19A1) or P450-oxidoreductase (POR). The typical signs of virilizing CAH are reflective of the androgen excess as well as the mineralocorticoid and glucocorticoid deficiencies. In general, the degree to which a given mutation results in reduction of enzyme activity is correlated to the level of glucocorticoid and mineralocorticoid deficiency. An additional CAH is caused by mutations that affect either the 17hydroxylase, 17, 20-lyase or both activities encoded in the CYP17A1 gene. Unlike the virilizing forms of CAH, in individuals harboring CYP17A1 mutations that result in severe loss of enzyme activity there is absent sex steroid hormone production accompanied by hypertension resulting from mineralocorticoid excess. Clinical Features of the CAHs: CYP21A2 deficiency: CAH resulting from deficiencies in the CYP21A2 gene represent the most commonly occurring forms (>95%) of the disease. The majority of the mutations in CYP21A2 that result in CAH have been identified and the severity of the disorder can be correlated to specific mutations and the consequent effect of the mutation on enzyme activity. Deficiencies in CYP21A2 result in decreased secretion and plasma concentration of cortisol. The reduced levels of cortisol result in a reduction in the negative feedback exerted by this hormone on the hypothalamic-pituitary axis. The reduced negative feedback leads to increased secretion of corticotropin releasing hormone (CRH) and ACTH. The resultant high plasma concentrations of ACTH are responsible for the adrenocortical hyperplasia characteristic of this disorder. Clinical features: CAH resulting from CYP21A2 deficiencies is divided into three distinct clinical forms. The most severe enzyme impairment mutations result in the salt-losing form.
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-Females with this form of the disease present at birth due to ambiguity in the external genitalia. Males with the salt-losing form present with acute adrenal crisis shortly after birth or in early infancy. Females who present with no acute adrenal crisis and only mild masculinization of the external genitalia and males who present with virilism early in life are considered be suffering from the simple virilizing form of CAH. The final clinical form of CAH manifests only in females at puberty or shortly thereafter with symptoms of mild excess androgen development resulting in hirsutism, amenorrhea, and infertility. This form of the disorder is referred to as the attenuated form or the late onset or nonclassic form. The 21-hydroxylase gene (CYP21A2, CYP21, CYP21B) is located within the class III region of the major histocompatibility complex (MHC) on chromosome 6. There are in fact, two CYP21 genes within this MHC locus but one of the two is a pseudogene and is identified as CYP21P. Older nomenclature identifies the CYP21P gene as the 21-hydroxylase A gene (or CYP21A1) and CYP21A2 as the 21-hydroxylase B gene. All 21-hydroxylase activity is synthesized from the mRNA encoded by the CYP21A2 gene. Forms of ACH: 1- Salt-losing CYP21A2 deficiency: In the salt-losing form of this disorder the degree of loss of enzyme activity is severe to complete. As a result of the level of enzyme deficiency the synthesis of cortisol is negligible. Because CYP21A2 is also needed for the synthesis of aldosterone, which is a major hormone involved in Na+ retention by the kidney, there is excessive salt loss leading to hyponatremic dehydration which can be fatal if not treated. Although there is some aldosterone made, the level of salt loss exceeds the ability of the adrenal cortex to make sufficient aldosterone to compensate. The net result is an acute adrenal crisis. The near complete, or complete, loss in cortisol production results in maximal activity of the CRH-ACTH axis leading to maximal adrenal androgen secretion with the result being masculinization of the female genitalia.

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The first sign of CAH due to CYP21A2 deficiency is the ambiguous female genitalia in neonates. The masculinization can be so extreme as to result in the fusion of the labia and the formation of a penile urethra. Diagnosis of the salt-losing form of this disorder is made in females born with masculinized genitalia, who are of normal 46,XX karyotype, with marked elevation in plasma 17-hydroxyprogesterone and androstenedione, as well as serum chemistry showing hyponatremia, hypochloremia and hyperkalemic acidosis. 2- Simple virilizing CYP21A2 deficiency: In the simple virilizing form of the disorder the deficiency in CYP21A2 is not complete or as severe as in the saltlosing form. As a result the adrenal cortex can compensate for salt loss with increased aldosterone synthesis and release. In addition, the increased ACTH release result in normal plasma cortisol levels and thus, there is no glucocorticoid deficit. However, as in the salt-losing form the CRH-ACTH axis is hyperactive leading to excessive adrenal androgen synthesis with consequent masculinization of the female genitalia. 3- Attenuated CYP21A2 deficierncy: As the name of this form of disease implies, patients with the attenuated form exhibit only mild reductions in CYP21A2 activity. Symptoms associated with this form of the disorder manifest in females at puberty. There are no signs of masculinization of the genitalia in females with this form of the disease. Although females have relatively normal breast development, the androgen excess results in excessive body hair (hirsutism), amenorrhea and the development of small ovarian cysts. CYP11B1 deficiency: CAH due to deficiencies in 11-hydroxylase (CYP11B1), although rare, are the second most commonly occurring forms of these disorders being found in approximately 5% of CAH patients. CYP11B1 deficiency was originally identified as a hypertensive form of CAH. Deficiency of CYP11B1 activity in the zona fasciculata results in impaired reductions in cortisol and corticosterone synthesis. In addition, the loss of negative feedback on the hypothalamic-pituitary axis leads to increased ACTH release with the consequent increase in production of deoxycorticosterone (DOC), 11-deoxycortisol, and 18-hydroxy DOC.
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The hypertension seen in this form of CAH is due to the increased secretion of DOC which suppresses the renin-angiotensin system leading to very low aldosterone secretion. Because there is hypersecretion of ACTH and a block in the normal pathway to corticosteroid synthesis there is an androgen excess similar to that seen in the CYP21A2 deficiency forms of CAH. As a result, females exhibit masculinized genitalia. The CYP11B1 gene is located on chromosome 8q21 spanning 6.5kbp and composed of 9 exons encoding a 502 amino acid enzyme. The protein encoded by the CYP11B1 gene includes a 24 amino acid mitochondrial localization signal. HSD3B2 deficiency: CAH due to deficiencies in 3-hydroxysteroid dehydrogenase represent less than 1% of all cases. When the deficiency is severe there is a near total absence of adrenal steroids. Thus there are deficiencies in the glucocorticoids, mineralocorticoids, as well as adrenal androgens. The impaired corticosteroid synthesis results in symptoms of adrenal insufficiency that can be fatal if not treated during the neonatal period. Several steroid precursors accumulate including pregneneolone and DHEA as well as their hydroxylated derivatives. Females with this disorder will present with slight fusion of the labia and an enlarged clitoris, while males present with ambiguous genitalia. Correct diagnosis of this disorder can be made by measurement of the levels of DHEA, 17-hydroxypregnenolone and 16-hydroxy-DHEA in the urine and serum. The HSD3B2 gene is located on chromosome 1p13.1. POR deficiency: Cytochrome P450 oxidoreductase (POR) is a flavoprotein that donates electrons to all microsomal P450 enzymes. In the context of adrenal streroidogenesis, POR functions as the electron donor for CYP17A1, CYP21A2, and CYP19A1. Deficiencies in POR result in ambiguous genitalia in both males and females. Some of the skeletal malformations resulting from POR deficiency resemble Antley-Bixler syndrome (ABS), however ABS is not associated with disordered
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steroidogenesis. These skeletal malformations include midface hypoplasia, low set ears, craniosynostosis (premature fusion of the cranial sutures), choanal atresia (blockage in the back of the nasal passage), and fusion of the arm bones. CAH resulting from POR deficiencies are rare. The POR gene is located on chromosome 7q11.2 Placental aromatase (CYP19A1) deficiency: The aromatase gene (also called estrogen synthetase) is expressed in ovaries, placenta, and extragonadal tissues such as adipose tissue, liver, brain, muscle, and hair follicles. The activity of the enzyme is to convert androgens to estrogens. During fetal development the fetal adrenal glands secrete DHEA-S as the substrate for placental estrogen production. The loss of CYP19A1 activity results in decreased placental estrogen production and increased androgen precursors. Female infants may have masculinized external genitalia. The CYP19A1 gene is located on chromosome 15q21.1 spanning 70kbp and composed of 10 exons encoding a 503 amino acid enzyme. CYP17A1 deficiency: The CYP17A1 enzyme catalyzes both the 17hydroxylase and 17, 20-lyase (side-chain removal) reactions of adrenal steroidogenesis. Similar to each of the above described CAH, the underlying clinical manifestations of CYP17A1 deficiency are due to the inability to produce normal levels of glucocorticoids with the consequences being a loss of the feedback inhibition of the hypothalamic-pituitary axis resulting in elevated ACTH secretion. However, symptoms in these patients are less severe than in other forms of CAH. Patients with 17-hydroxylase deficiency do not make cortisol but do produce large amounts of corticosterone. Corticosterone does bind the glucocorticoid receptor but with an affinity 1/100th that of cortisol. Deoxycorticosterone (DOC), which serves as the precursor to corticosterone, exhibits significant mineralocorticoid activity. This fact explains the hypertension exhibited in 17-hydroxylase deficient patients. A deficiency in the 17, 20-lyase activity of CYP17A1 leads to loss of C-18 and C-19 steroids from C-21 precursors leading to impaired production of androgens and estrogens. Affected males have defective genital development in utero and present with ambiguous external genitalia at birth. Development of female genitalia in utero
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does not require endogenous sex steroid production thus, affected females present at birth with normal external genitalia. However, female patients will present at puberty with infantile breasts, primary amenorrhea, absent or scant axillary and pubic hair, and hypogonadism. The CYP17A1 gene is located on chromosome 10q24.3 and is composed of 8 exons encoding a 508 amino acid enzyme. Deficiency in CYP17A1 is extremely rare with more than 90% of reported cases having deficiency in the both the 17hydroxylase and 17,20-lyase activities or just 17-hydroxylase. The remainder of reported cases have deficiency in only the 17,20-lyase activity.

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Biosynthesis of adrenal steroids

References:
-Lippincott s illustrated biochemistry. 4th ed. Pamela C. Champe, Richard A. Harvey and Denise R. Ferrier. R.R. Donnelley & Son'sWillard, Ohio -Harpers Illustrated Biochemistry 26th ed. Robert K. Murray, Daryl K. Granner and Peter A. Mayes and Victor W. Rodwell. Lange Medical Books/McGraw-Hill. New York Chicago San Francisco -Lehninger principles of biochemistry, 4th ed. David L. Nelson and Michael L. Cox. -Inherited metabolic diseases : clinical approch. (2010) : Georg F. Hoffmann, Johannes Zschocke and William L. Nyhan (Eds.). Springer Heidelberg Dordrecht London New York

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