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By Prof. MANAL ELDEFRAWY Awareness of some IEM 2011. Management of Metabolic Emergencies. Objectives. When to suspect a metabolic disorder ? Immediate investigations Specific investigations Which emergency measures ? Diagnostic algorithm Case presentation.

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by prof manal eldefrawy awareness of some iem 2011
By

Prof. MANAL ELDEFRAWY

Awareness of some IEM 2011

Management of Metabolic Emergencies

objectives
Objectives
  • When to suspect a metabolicdisorder?
  • Immediate investigations
  • Specific investigations
  • Which emergency measures?
  • Diagnostic algorithm
  • Case presentation
slide3

Single gene defect in an enzyme or transport protein, which results in a block in a metabolic pathway of proteins ,CHO, fats, or complex molecules.

  • Effects are due to:

toxic accumulations of substrates before the block, intermediates from alternative metabolic pathways, defects in energy production caused by a deficiency of products beyond the block,

or a combination of these metabolic deviations

slide4

The incidence, collectively, is

estimated to be approximately

1 in 4000 live births

The inheritance is mostly autosomal recessive with male to female ratio of 1:1

when to think metabolic
WhenTo think Metabolic

Time & Pattern of Onset

Neonatal period

  • Intoxication type

Typically born healthy, symptom free period

Deterioration with poor feeding, vomiting, lethargy, apnea seizures, coma.

e.g. a.acidopathies, Organic acidemia, UCDs , CHO intolerance.

B) Energy deficiencies

No apparent Symptom free

Overwhelming neurologic deterioration apnea, seizures, coma

e.g. FAO defects, Mitochondrial disorders, peroxisomal disorders

when to think metabolic beyond neonatal period
When To Think Metabolic?Beyond neonatal period
  • Lethargy or just not doing well
  • Refusal to feed poor suckling
  • Vomiting
  • Poor weight gain
  • Hepatomegaly
  • Tachypnea
  • Hypothermia
  • Axial hypotonia
  • Limb hypotonia
  • Abnormal movements(pedalling , tremors)
  • Altered conscious, seizures, coma
  • Multivisceral failure
when to think metabolic7
When to think metabolic?

Additional factors

  • Consanguinity
  • Unexplained Neonatal deaths
  • Unexplained Deterioration with symptomatic treatment
initial investigations parallel to sepsis screening
Initial investigations parallel to Sepsis screening
  • Urine
  • Ketonuria bedside test
  • Unusual Odour
  • Unusual colour
  • Reducing subtances
  • Blood
  • Glucose
  • Electrolytes: Na,K,cl,Ca
  • Ammonia
  • Blood gases
  • Anion gap
  • Transaminases
  • Prothrombin T&C & INR
  • Urea & creatinine
  • Uric acid
  • Lactic acid
  • CK
  • CBC
second line evaluation
Second Line Evaluation
  • Urine and plasma aminogram
  • Urine organic acid profile by GC-MS
  • Plasma carnitine and Acylcarnitine profile:

Increase carnitine ester in fatty acid oxidation defect, organic academias, ketosis

  • Dried blood spot analyzed by tandem mass spectrometry (MS/MS).
second line evaluation cont
Second Line Evaluation(cont.)
  • CSF anaylsis

NKH is diagnosed by the presence of elevated CSF to plasma glycine ratio

Decrease CSF glucose/to blood glucose…..glucose transporter defect

  • Peroxisomal function Test

Plasma very long chain fatty acids (VLCFAS),

Phytanic acid, erythrocyte plasmalogen levels

  • Stored samples

Frozen whole and heparinized bl., serum, CSF & urine (store at -20°C).

slide12

Emergent treatment of IEMs (acute life-threatening )

  • Establish airway, breathing, circulation.
  • Avoid lactated Ringer’s.
  • Avoid hypotonic fluid load due to the risk of cerebral edema (if hyperammonemia is present).
  • NPO :Discontinue intake of offending agents; (especially no protein, galactose, or fructose)
  • Provide adequate glucose to prevent catabolism. (Fluidboluses D10 normal saline).
slide13
Most IEMs with acute life-threatening presentation can be categorized based on finding of at least 1 of the following :
  • Hyperammonemia
  • Metabolic acidosis
  • Hypoglycemia
  • Jaundice and Liver dysfunction
hypoglycemia
Hypoglycemia

Severe, persistent, without other etiology

If with metabolic acidosis e.g. OA,

GSD Type 1 , Fructose 1,6Diphosphatase deficiency, FAO (hallmark Non ketotic)

N.B :Hypoglycemia (plasma glucose level

< 50 mg/dL)

treatment of hypoglycemia
Treatment ofHypoglycemia
  • D10 to D15 with electrolytes 8-12 mg/kg/min IV to maintain serum glucose leveat 120–170mg/dL which should prevent catabolism.
  • High-volume maintenance fluid 1-1.5 times maintenance will also promote urinary excretion of some toxic metabolites.
  • If necessary, treat hyperglycemia with insulin (0.2-0.3 IU/kg/h) to maintain glucose level in the desired range.
hyperammonemia
Hyperammonemia
  • Excess ammonia (about80% dietary and waste nitrogen) is converted to urea in the liver through urea cycle.
  • The five enzymes that make up the urea cycle are regulated long term by the quantity of dietary protein.
  • Ammonia level :

>100 mcg/dL in the neonate

> 80 mcg/dL beyond the neonatal period

is considered elevated & toxic.

hyperammonemia18
Hyperammonemia

This can lead to Encephalopathy and death OR

Devastating neurological sequelae.

Neurological sequelae and survival depend on the length of hyperammonemic coma(better prognosis <36h or<2days).

hyperammonemia19
Hyperammonemia
  • Significant hyperammonemia is observed in
      • Urea cycle defect
      • Organic acidemia
      • Fatty acid oxidations defects
      • THAN
  • Ammonia is highest in the UCDs often exceeding 1000 mcg/dL and causing primary respiratory alkalosis sometimes with compensatory metabolic acidosis.
  • Ammonia in OA, if elevated, rarely exceeds 500 mcg/dL, and in FAO is usually less than 250 mcg/dL.
slide20

Hyperammonemia

Acidosis

Normal PH or alkalosis

Organic acidemiaPyruvate metabolism

Normoglycemia

Hypoglycemia Hypoketosis

Plasma aminoacids Urea cycle disorders

Fatty acid oxidation (FAO)

Increased citrulline

ASA present

Increased

Citrulline

ASA absent

Low/Normal citrulline

Urine Orotic acid

Citrullinemia

Argininosuccinicacidemia

OTC deficiency

CPS deficiency

THAN

slide21

The therapeutic protocol include :

  • Avoidance of nitrogen intake by nasogastric infusion of a protein-free formula.
  • Adequate caloric intake (80-120 kcal/kg/d) by glucose (10 – 20 g/kg ) .
  • Sodium benzoate (250-500 mg/kg/d),more recently phenylbutyrate(250mg/kg/d) peroral
  • IV administration of arginine(250-500mg/kg/d)
  • Carnitine(250-500 kg/d)
  • Hydroxycobalamin( 1mg/d)
  • Biotin( 10 mg/d)
  • Insulinmay be added to utilize its anabolic effect (0.1 -1 IU /kg/ hr if bl. glucose > 200 mg/dl )
  • Dialysisin patients not responding to pharmacological therapy
case presentation
Case presentation
  • A 3 years old boy presented to ER with disturbed level of consciousness of 2 days duration triggered by fever and associated with one brief attack of generalized tonic clonic seizures.
  • The day before he ate high protein containing food which was followed by :

period of hyperirritability and profuse vomiting

then gradual and progressive lapse in the level of consciousness which worsen upon the introduction of depakene to control the seizure .

slide23

Past history : revealed two similar episodes of disturbed conscious level :

-The first was at 7days in neonatal period .

CT at that time revealed brain edema.

-The second episode was at the age of 18 months.

  • Examination :

revealed a semi conscious child with generalized axial and limb hypotonia,

RR 50/m.

slide24

Lab investigation

  • Blood gases: ph=7.5 , Pco2=24 ,Hco3=18
  • Ammonia level =250mg/dl
  • Lactate = 3.2 mmol/l ( n < 2.1 )
  • Normal LFT &KFT
  • CBC: mild neutrophilia
  • Salient features
    • Disturbed conscious level
    • respiratory alkalosis
    • Hyperammonemia
slide25

MS/MS revealed very high level of citrulline

  • Orotic acid in urine wasincreased
  • Final diagnosis: citrullinemia
ms ms
MS/MS

Normal

Citrullinemia

hhh syndrome
HHH syndrome
  • One year & 1mth old boy with severe failure to thrive , excessive sleepiness .
  • The condition started at the age of 4mths after feeding baby with yogurt . He started to have recurrent attacks of vomiting sometimes with diarrhea ,admitted to hospital for IV fluids.
  • On examination:

Fair complexion , apathy , GDD (motor &mental) . Normal abd. Exam. Pt . weighted 6 kg , H.C. 42 cm , length 69 cm (all< 3rd percentile for age)

hhh cont
HHH cont.
  • Investigations:

HGB : 10.5 , normocytic,normochromic a.

ABG: metabolic alkalosis ( repeatedly)

Ammonia : high ( repeatedly) > 300ug/dl TMS: ( HHH syndrome)

Hyperammonemia,

Hyperornithinemia and Homocitrullinemia

metabolic acidosis
Metabolic Acidosis
  • Among the inborn errors, the largest group typically associated with overwhelming metabolic acidosis in infancy is the group of organic acidemias
      • Methylmalonicacidemia,
      • Propionicacidemia, and
      • Isovalericacidemia.
important laboratory findings in organic acidemia
Important Laboratory Findings in Organic Acidemia
  • Hyperlacticacidemia
  • Neutropenia and thrombocytopenia
  • Hyperammonemia
  • Ketosis
emergency management of metabolic acidosis
Emergency management of metabolic Acidosis
  • Metronidazole(10-20mg/kg) and neomycin (50mg/kg) reduce the level of priopionic acid and methyl malonic acid in body fluid
  • Antibioticas clindamycin and vancomycin.
  • Hyperammonemic episodesshould be treated promptly with Na benzoate(250mg/kg in10% glucose)
  • Aggressive fluid and electrolytetherapy is essential in acute ketoacidotic crisis: 150mg-200mg/kg of 10% glucose and isotonic NAHCO3 until acidosis is corrected: 0.25-0.5 mEq/kg/h (up to 1-2 mEq/kg/h) IV
  • Consider hemodialysis; if intractable acidosis, (peritoneal dialysis, hemofiltration, exchange transfusion much less effective).
methylmalonic acidemia
Methylmalonic acidemia
  • Marked failure to thrive
  • severe metabolic acidosis
  • ketosis
  • Severe psychomotor retardation
  • Encephalopathy
  • Dystonia
  • Recurrent seizures
  • Peritoneal dialysis
brain mri
Brain MRI
  • T2w MRI demonstrating bilateral and symmetrical high signal intensity lesions in the globuspallidus
slide38
MMA

Date : 9/2010

- 2 years old male

-3mths ago he developed recurrent attacks of G.E. & M.A.

-Then he suffered from coma for nearly a week ?.

-After that he developed severe failure to thrive.

Expanded metabolic screen using LC-MS/MS showed

MMA

ethyl malonic acidemia
Ethyl MalonicAcidemia
  • A.A, the 3rd child of first degree consanguineous parents whose birth date is 8/2008
  • The patient presented at the age of 9 months with GDD and intractable seizures
  • Antenatal, natal and perinatal period were uneventfull
  • Clinical exam revealed, microcephaly, microphthalmia, frontal bossing, hypertolerism, epicanthic folds, long filtrum and bat ears
ethyl malonic acidemia40
Ethyl MalonicAcidemia
  • Neurological exam revealed hypertonia, hyperreflexia, positive babinski , truncalhypotonia.
  • Recurrent ecchymotic patches on the lower limb
  • No episodes of metabolic decompensation or metabolic acidosis
  • Pt. has a normal 4 years aged sister and mother had one abortion
ethyl m alonic a cidemia
Ethyl MalonicAcidemia
  • TMS result:
  • elevated butyrylcarnitine (C4) =4. micomol/L cut off value =1.5 micromol/L
  • Urine organic acid analysis by GC-MS showed
    • highly elevated Ethylmalonic acid
    • and moderately elevated methylsuccinic acid
    • no dicarboxylicaciduria and
    • no lactic aciduria
brain mri in ema
Brain MRI in EMA

T2w Brain MRI showing widening of extraaxial CSF spaces, and sylvian fissure, picture of severe brain atrophy

TW1 Brain MRI showing frontotemporal atrophy

slide43
Ethyl malonicacidemia
  • Five mths old girl coming from Gaza(during 25 January revolution 2011) with recurrent attacks of diarrhea, vomiting ,with severe napkin dermatitis and failure to thrive.
  • Clinical exam. revealed, microcephaly, frontal bossing, hypertolerism, epicanthic folds, long filtrum and bat ears
  • She weighted 3 kg , she had hyperammonemia , met . acidosis .
  • TMS : Ethyl malonicacidemia
pyroglutamic aciduria
Pyroglutamicaciduria
  • 3 mths old boy ,1st baby
  • Admitted to PICU due to DCL , shortness of breath, increased yellowish discoloration of skin after severe attacks of vomiting for previous 2 days not associated by diarrhea.
slide45

History

The condition started at the age of 5 days by

Jaundice which was diagnosed as physiological , no treatment .

For the following 3 month the mother noticed gradual abd . distention and no improvement in colour .

On examination

the baby was lethargic with tachypnea , hepatomegaly (span 10cm ) and cholestatic jaundice ( T=9.6 , d=5.2).

He was ventilated but it was difficult

to be weaned from vent. as he developed cardiac problems as severe bradycardia and arrest.

slide46

Investigations

  • CBC: HB 10gm% , WBC :24,000
  • Bil total: 9.6 Direct :5.2 mg/dl
  • ALT :115 . PT :26, INR:2.9
  • Urea :30 , creatinine:0.7
  • CRP: 12
  • ABG : variable with increased anion gap 59
  • Bl. Ammonia : 607---- 230---303 ug/dl
  • MS/MS : Pyroglutamicaciduria
  • Urineorganic acids was done
slide47

The baby was treated with Na benzoate and glutathione analogs, vit C and vit E.He started to gain consciousness and he was weaned from the vent. The jaundice and hepatomegaly decreases .

slide49

2.8 years old

  • At the age of 2y , she developed recurrent attacks of convulsions and was treated with antiepileptic drugs
  • At 2.1 y, she suffered recurrent attacks of RD with metabolic acidosis , no hypogycemia ,no hep.
  • Then she went in coma for 1 d.
  • Bl Ammonia level was elevated
  • so she received Na benzoate
  • She improved for 2w then amm. increased again.
  • MS/MS was normal
  • ALT ,AST were 2-3 times normal
  • There was no hypoglycemia during
  • the illness
  • Liver span 10 cm, firm
  • Liver biopsy 10/8/2010
  • metabolic LD ---- GSD
slide51

Hepatocellular necrosis, acute or subacute

galactosemia

  • There are three known enzymatic errors .
  • The most common defect is decreased activity of galactose 1-phosphate uridyltransferase (GALT)
  • Clinical manifestations include :

lethargy, hypotonia, jaundice.

Hypoglycemia, elevated liver enzymes

Coagulopathy

slide52

Diagnosis

  • Reducing substances in infants urine with simultaneous normal orlow blood sugarwhile the infant is being fed breast milk or a formula containing lactose.
  • enzyme activity measurement in erythrocytes .
  • Prenatal diagnosis by direct measurement of the enzyme activity(GALT).
slide54

Treatment

  • The main is lactose-free formula followed by dietary restriction of all lactose-containing foods later in life.
  • Untreated infants may have severe growth failure, mental retardation, cataracts, ovarian failure, and liver cirrhosis.
  • Despite early and adequate intervention, some children still may develop milder signs of these clinical manifestations.
slide56

Hereditary fructose intolerance (HFI)

  • Alternative names
  • Fructosemia; Fructose intolerance; Fructose aldolase B-deficiency; Fructose 1, 6 bisphosphatealdolase deficiency
  • An autosomal recessive disorder
  • Although glucose may still be released through the breakdown of glycogen ,it cannot be synthesized from gluconeogenesis, resulting in severe hypoglycaemia
slide58

Tests that confirm the diagnosis

  • Positive urine test for reducing substances .
  • Hypoglycemia , especially after receiving fructose/sucrose .
  • Abnormally high amounts of amino acids and salts in urine
  • Enzyme studies
  • Treatment
  • Complete elimination of fructose and sucrose from the diet is an effective treatment for most patients.
slide59

TYROSINEMIA TYPE I (TTI)

  • Autosomal recessive disorder
  • Incidence of 1:100,000 to 1:120,000.
  • The defect is in fumarylacetoacetatehydrolase, resulting in accumulation of metabolites such as fumarylacetoacetate and malelylacetoacetate which are alkylating agents that cause damage to DNA and predisposition to HCC.
  • One of the byproducts of these metabolites is succinyl acetone, which is a diagnostic marker for tyrosinemia .
slide60

Presentation of TTI

  • Include :
  • Acute liver failure, chronic liver disease, HCC.
  • Renal tubular dysfunction.
  • Episodic porphyria-like neurological episodes(42% of patients )caused by succinyl acetone inhibiting the metabolism of aminolevulinic acid.
  • Neurological crises began at a mean age of 1 year. Episodes included severe pain with extensor hypertonia, vomiting or paralytic ileus, muscle weakness, and self-mutilation.
slide62

Diagnosis

  • Serum amino acid patterns may exhibit high levels of tyrosine, phenylalanine and methionine.
  • Generalized aminoaciduria.
  • High levels of alpha-fetoprotein are observed.
  • succinyl acetone in urine and serum is a diagnostic marker for tyrosinemia.
  • Enzyme measurement in lymphocytes &RBC
slide63

Product ion scans of derivatized SA (top) and 5,7- dioxooctanoic acid (internal standard; bottom) and fragmentation of SA-hydrazone (inset).

A simple method for quantifying SA in dried blood spots hasbeen described by Allard et al.,2004 .

Inclusion of SA in our existing screening program couldbe achieved with little additional manual work.

slide64

The medical management of TTI

  • Has changed considerably with the introduction of 2-(2-nitro-4-trifluoromethylbenzol)-1,3-cyclohexendiome (NTBC) in 1992.
  • NTBC blocks the second step in tyrosine degradation, thus preventing formation of the alkylating metabolites.
  • Currently, the indication for transplantation includes treatment failure or development of HCC.
slide65

WILSON'S DISEASE

  • An autosomal recessive disease.
  • The specific molecular defect resides within a copper-transporting ATPase encoded by a gene on chromosome 13.
  • Affected patients exhibit impaired biliary excretion of copper; this leads to copper accumulation in the liver , brain, cornea, and kidneys.
slide66

Clinical presentation

  • The most common presentation is that of postnecrotic cirrhosis with hepatic dysfunctionand portal hypertension or chronic active hepatitis.
  • The disease may manifests as fulminant hepatic failure; with massive liver necrosis, coincident hemolysis .
slide67

Diagnosis

  • A useful screening test is low serum ceruloplasmin. It is < 20 mg per dl in 85% of patients.
  • The presence of Kayser-Fleischer rings.
  • Increased urinary excretion of copper.
  • Elevated liver copper on biopsy.

Patients with > 250 µg copper per gram of dry liver tissue are considered to have Wilson's disease.

  • Measurement of urinary copper excretion in response to oral penicillamine challenge .
slide68
The Kayser–Fleischer ring around the periphery of the cornea caused by deposition of copper in Descemet's membrane
hyperintensities in the bilateral basal ganglia and thalami shown by t2 weighted mri of the brain
Hyperintensities in the bilateral basal ganglia and thalami shown by T2-weighted MRI of the brain

Das SK and Ray K (2006) Wilson's disease: an update

Nat ClinPractNeurol2: 482–493

slide70

Treatment

  • Copper chelationimproves survival. Treatment includes D-penicillamine, triethylenetetraminedihydrochloride(tientene; generally used in D-penicillamine-intolerant patients), and oral zinc.
  • Once initiated, therapy must be continued for life; discontinuation can result in rapid deterioration.
  • liver transplantation in patients with fulminant hepatic failure or decompensated cirrhosis, provides effective therapy.