Advertisement

Journal of Inherited Metabolic Disease

, Volume 41, Issue 6, pp 1169–1178 | Cite as

The diagnostic challenge in very-long chain acyl-CoA dehydrogenase deficiency (VLCADD)

  • Julia Hesse
  • Carina Braun
  • Sidney Behringer
  • Uta Matysiak
  • Ute Spiekerkoetter
  • Sara TucciEmail author
Original Article

Abstract

Very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) is the most common defect of mitochondrial β-oxidation of long-chain fatty acids. However, the unambiguous diagnosis of true VLCADD patients may be challenging, and a high rate of false positive individuals identified by newborn screening undergo confirmation diagnostics. In this study, we show the outcome of enzyme testing in lymphocytes as a confirmatory tool in newborns identified by screening, and the correlation with molecular sequencing of the ACADVL gene. From April 2013 to March 2017, in 403 individuals with characteristic acylcarnitine profiles indicative of VLCADD, palmitoyl-CoA oxidation was measured followed by molecular genetic analysis in most of the patients with residual activity (RA) <50%. In almost 50% of the samples (209/403) the RA was >50%, one-third of the individuals (125/403) displayed a RA of 30–50% and 69/403 individuals showed a residual activity of 0–30%. Sequencing of the ACADVL gene revealed that all individuals with activities below 24% were true VLCADD patients, individuals with residual activities between 24 and 27% carried either one or two mutations. Twenty new mutations could be identified and functionally classified based on their effect on enzyme function. Finally, we observed an up-regulation of MCAD-activity in many patients. However, this did not correlate with the degree of VLCAD RA. Although the likely clinical phenotype cannot be fully foreseen by genetic and functional tests as it depends on many factors, our data demonstrate the strength of this functional enzyme test in lymphocytes as a quick and reliable method for confirmation diagnostics of VLCADD.

Abbreviations

FAOD

Fatty acid oxidation disorders

MCAD

Medium-chain acyl-CoA dehydrogenase

MCFA

Medium-chain fatty acids

NBS

Newborn screening

RA

Residual activity

VLCAD

Very long-chain acyl-CoA dehydrogenase

Notes

Acknowledgements

All authors read, drafted and approved the final manuscript. JH conducted the research and drafted the manuscript; ST designed the research, wrote the manuscript and had primary responsibility for final content; CB and SB were responsible for enzyme testing; UM supported the interpretation of the molecular genetics data; US drafting the article and revised it critically for important intellectual content. The study was financially supported by a grant from the Eva-Uth- and Müller-Fahnenberg Foundations given to Sara Tucci.

Compliance with ethical standards

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). The study was approved under study number 78/18 by the ethical review board of Albert-Ludwig University of Freiburg. Informed consent was obtained from all patients for being included in the study.

Conflict of interest

Sara Tucci has received a grant and travel reimbursements by Vitaflo and Dr. Schär unrelated to this study. Julia Hesse, Carina Braun, Sidney Behringer, Uta Matysiak and Ute Spiekerkoetter declare that they have no conflict of interest.

Supplementary material

10545_2018_245_MOESM1_ESM.xlsx (31 kb)
Suppl. Table 1 Genetic testing results, VLCAD residual activity, MCAD activity and C14:1 carnitine on NBS in patients suspected for VLCADD. aActivity was given as % of the mean value of healthy controls (12.2 ± 1.6 mU/mg). bNewborn screening initial C14:1 carnitine is expressed in μmol/L. Cut-off values are shown in brackets. Bold – novel mutation *Mutations were on the same allele. ns: not sequenced (XLSX 31 kb)

References

  1. Andresen BS, Olpin S, Poorthuis BJ et al (1999) Clear correlation of genotype with disease phenotype in very-long-chain acyl-CoA dehydrogenase deficiency. Am J Hum Genet 64(2):479–494CrossRefPubMedCentralGoogle Scholar
  2. Arnold GL, Van Hove J, Freedenberg D et al (2009) A Delphi clinical practice protocol for the management of very long chain acyl-CoA dehydrogenase deficiency. Mol Genet Metab 96(3):85–90CrossRefPubMedCentralGoogle Scholar
  3. Boneh A, Andresen BS, Gregersen N et al (2006) VLCAD deficiency: pitfalls in newborn screening and confirmation of diagnosis by mutation analysis. Mol Genet Metab 88(2):166–170CrossRefGoogle Scholar
  4. Bouvier D, Vianey-Saban C, Ruet S, Acquaviva C (2017) Development of a tandem mass spectrometry method for rapid measurement of medium- and very-long-chain acyl-CoA dehydrogenase activity in fibroblasts. JIMD Rep 35:71–78CrossRefGoogle Scholar
  5. Burrage LC, Miller MJ, Wong LJ et al (2016) Elevations of C14:1 and C14:2 plasma acylcarnitines in fasted children: a diagnostic dilemma. J Pediatr 169:208–213 e202CrossRefGoogle Scholar
  6. Chace DH, Kalas TA, Naylor EW (2003) Use of tandem mass spectrometry for multianalyte screening of dried blood specimens from newborns. Clin Chem 49(11):1797–1817CrossRefGoogle Scholar
  7. Diekman EF, Ferdinandusse S, van der Pol L et al (2015) Fatty acid oxidation flux predicts the clinical severity of VLCAD deficiency. Genet Med 17(12):989–994CrossRefGoogle Scholar
  8. Diekman E, de Sain-van der Velden M, Waterham H et al (2016) The newborn screening paradox: sensitivity vs. Overdiagnosis in VLCAD deficiency. JIMD Rep 27:101–106CrossRefGoogle Scholar
  9. Gramer G, Haege G, Fang-Hoffmann J et al (2015) Medium-chain acyl-CoA dehydrogenase deficiency: evaluation of genotype-phenotype correlation in patients detected by newborn screening. JIMD Rep 23:101–112CrossRefPubMedCentralGoogle Scholar
  10. Gregersen N, Andresen BS, Corydon MJ et al (2001) Mutation analysis in mitochondrial fatty acid oxidation defects: exemplified by acyl-CoA dehydrogenase deficiencies, with special focus on genotype-phenotype relationship. Hum Mutat 18(3):169–189CrossRefGoogle Scholar
  11. Hoffmann L, Haussmann U, Mueller M, Spiekerkoetter U (2012) VLCAD enzyme activity determinations in newborns identified by screening: a valuable tool for risk assessment. J Inherit Metab Dis 35(2):269–277CrossRefGoogle Scholar
  12. Janzen N, Hofmann AD, Schmidt G, Das AM, Illsinger S (2017) Non-invasive test using palmitate in patients with suspected fatty acid oxidation defects: disease-specific acylcarnitine patterns can help to establish the diagnosis. Orphanet J Rare Dis 12(1):187CrossRefPubMedCentralGoogle Scholar
  13. Liebig M, Schymik I, Mueller M et al (2006) Neonatal screening for very long-chain acyl-coA dehydrogenase deficiency: enzymatic and molecular evaluation of neonates with elevated C14:1-carnitine levels. Pediatrics 118(3):1065–1069CrossRefGoogle Scholar
  14. Lindner M, Hoffmann GF, Matern D (2010) Newborn screening for disorders of fatty-acid oxidation: experience and recommendations from an expert meeting. J Inherit Metab Dis 33(5):521–526CrossRefGoogle Scholar
  15. Maier EM, Pongratz J, Muntau AC et al (2009) Dissection of biochemical borderline phenotypes in carriers and genetic variants of medium-chain acyl-CoA dehyrogenase deficiency: implications for newborn screening [corrected]. Clin Genet 76(2):179–187CrossRefGoogle Scholar
  16. Manning NJ, Olpin SE, Pollitt RJ, Webley J (1990) A comparison of [9,10-3H]palmitic and [9,10-3H]myristic acids for the detection of defects of fatty acid oxidation in intact cultured fibroblasts. J Inherit Metab Dis 13(1):58–68CrossRefGoogle Scholar
  17. Mathur A, Sims HF, Gopalakrishnan D et al (1999) Molecular heterogeneity in very-long-chain acyl-CoA dehydrogenase deficiency causing pediatric cardiomyopathy and sudden death. Circulation 99(10):1337–1343CrossRefGoogle Scholar
  18. Matsubara Y, Narisawa K, Miyabayashi S et al (1990) Identification of a common mutation in patients with medium-chain acyl-CoA dehydrogenase deficiency. Biochem Biophys Res Commun 171(1):498–505CrossRefGoogle Scholar
  19. Merinero B, Alcaide P, Martin-Hernandez E, et al (2017) Four years’ experience in the diagnosis of very long-chain acyl-coa dehydrogenase deficiency in infants detected in Three Spanish newborn screening centers. JIMD Rep 39:63–74Google Scholar
  20. Miller MJ, Burrage LC, Gibson JB et al (2015) Recurrent ACADVL molecular findings in individuals with a positive newborn screen for very long chain acyl-coA dehydrogenase (VLCAD) deficiency in the United States. Mol Genet Metab 116(3):139–145CrossRefPubMedCentralGoogle Scholar
  21. Olpin SE, Clark S, Dalley J et al (2017) Fibroblast fatty-acid oxidation flux assays stratify risk in newborns with presumptive-positive results on screening for very-long chain acyl-CoA dehydrogenase deficiency. Int J Neonatal Screen 3(1):2CrossRefGoogle Scholar
  22. Pena LD, van Calcar SC, Hansen J et al (2016) Outcomes and genotype-phenotype correlations in 52 individuals with VLCAD deficiency diagnosed by NBS and enrolled in the IBEM-IS database. Mol Genet Metab 118(4):272–281CrossRefPubMedCentralGoogle Scholar
  23. Rhead WJ (2006) Newborn screening for medium-chain acyl-CoA dehydrogenase deficiency: a global perspective. J Inherit Metab Dis 29(2–3):370–377CrossRefGoogle Scholar
  24. Schiff M, Mohsen AW, Karunanidhi A, McCracken E, Yeasted R, Vockley J (2013) Molecular and cellular pathology of very-long-chain acyl-CoA dehydrogenase deficiency. Mol Genet Metab 109(1):21–27CrossRefPubMedCentralGoogle Scholar
  25. Schuler AM, Gower BA, Matern D, Rinaldo P, Vockley J, Wood PA (2005) Synergistic heterozygosity in mice with inherited enzyme deficiencies of mitochondrial fatty acid beta-oxidation. Mol Genet Metab 85(1):7–11CrossRefGoogle Scholar
  26. Schymik I, Liebig M, Mueller M et al (2006) Pitfalls of neonatal screening for very-long-chain acyl-CoA dehydrogenase deficiency using tandem mass spectrometry. J Pediatr 149(1):128–130CrossRefGoogle Scholar
  27. Spiekerkoetter U, Sun B, Zytkovicz T, Wanders R, Strauss AW, Wendel U (2003) MS/MS-based newborn and family screening detects asymptomatic patients with very-long-chain acyl-CoA dehydrogenase deficiency. J Pediatr 143(3):335–342CrossRefGoogle Scholar
  28. Spiekerkoetter U, Lindner M, Santer R et al (2009) Treatment recommendations in long-chain fatty acid oxidation defects: consensus from a workshop. J Inherit Metab Dis 32(4):498–505CrossRefGoogle Scholar
  29. Spiekerkoetter U, Haussmann U, Mueller M et al (2010) Tandem mass spectrometry screening for very long-chain acyl-CoA dehydrogenase deficiency: the value of second-tier enzyme testing. J Pediatr 157(4):668–673CrossRefGoogle Scholar
  30. Sturm M, Herebian D, Mueller M, Laryea MD, Spiekerkoetter U (2012) Functional effects of different medium-chain acyl-CoA dehydrogenase genotypes and identification of asymptomatic variants. PLoS One 7(9):e45110CrossRefPubMedCentralGoogle Scholar
  31. Tajima G, Sakura N, Shirao K et al (2008) Development of a new enzymatic diagnosis method for very-long-chain acyl-CoA dehydrogenase deficiency by detecting 2-hexadecenoyl-CoA production and its application in tandem mass spectrometry-based selective screening and newborn screening in Japan. Pediatr Res 64(6):667–672CrossRefGoogle Scholar
  32. ter Veld F, Mueller M, Kramer S et al (2009) A novel tandem mass spectrometry method for rapid confirmation of medium- and very long-chain acyl-CoA dehydrogenase deficiency in newborns. PLoS One 4(7):e6449CrossRefPubMedCentralGoogle Scholar
  33. Tucci S, Behringer S, Spiekerkoetter U (2015) De novo fatty acid biosynthesis and elongation in very long-chain acyl-CoA dehydrogenase-deficient mice supplemented with odd or even medium-chain fatty acids. FEBS J 282(21):4242–4253CrossRefGoogle Scholar
  34. Vockley J, Rinaldo P, Bennett MJ, Matern D, Vladutiu GD (2000) Synergistic heterozygosity: disease resulting from multiple partial defects in one or more metabolic pathways. Mol Genet Metab 71(1–2):10–18CrossRefGoogle Scholar
  35. Wanders RJ, Vreken P, den Boer ME, Wijburg FA, van Gennip AH, IJ L (1999) Disorders of mitochondrial fatty acyl-CoA beta-oxidation. J Inherit Metab Dis 22(4):442–487CrossRefGoogle Scholar
  36. Wanders RJ, Ruiter JP, L IJ, Waterham HR, Houten SM (2010) The enzymology of mitochondrial fatty acid beta-oxidation and its application to follow-up analysis of positive neonatal screening results. J Inherit Metab Dis 33(5):479–494CrossRefPubMedCentralGoogle Scholar

Copyright information

© SSIEM 2018

Authors and Affiliations

  • Julia Hesse
    • 1
    • 2
  • Carina Braun
    • 1
    • 2
  • Sidney Behringer
    • 1
    • 2
  • Uta Matysiak
    • 3
  • Ute Spiekerkoetter
    • 1
  • Sara Tucci
    • 1
    • 2
    Email author
  1. 1.Department of General Pediatrics, Center for Pediatrics and Adolescent MedicineMedical Centre- University of Freiburg, Faculty of Medicine, University of FreiburgFreiburgGermany
  2. 2.Laboratory of Clinical Biochemistry and Metabolism, Center for Pediatrics and Adolescent MedicineMedical Center – University of Freiburg, Faculty of Medicine, University of FreiburgFreiburgGermany
  3. 3.Pediatric Genetics, Center for Pediatrics and Adolescent MedicineMedical Centre- University of Freiburg, Faculty of Medicine, University of FreiburgFreiburgGermany

Personalised recommendations