Cholestasis and Hepatic Iron Deposition in an Infant With Complex Deficiency Diana Montoya-Williams, MD, Meredith Mowitz, MD, MS

We present a 6-week-old male infant with persistent hyperbilirubinemia, abstract , elevated creatine kinase levels, and transaminitis since the second week of life. When he developed hyperkalemia, clinical suspicion was raised for despite hemodynamic stability. A full endocrine workup revealed nearly absent adrenocorticotropic hormone. Coupled with his persistent hypertriglyceridemia (peak of 811 mg/dL) and elevated creatine kinase levels (>20 000 U/L), his corticotropin level lead to a clinical diagnosis of complex glycerol kinase deficiency (GKD), also known as Xp21 deletion syndrome. This complex disorder encompasses the phenotype of Duchenne muscular dystrophy, GKD, and congenital adrenal hypoplasia due to the deletion of 3 contiguous genetic loci on the X chromosome. Division of Neonatology, Department of Pediatrics, Our case exemplifies the presentation of this disorder and highlights the University of Florida, Gainesville, Florida important lesson of distinguishing between adrenal hypoplasia congenita and congenital adrenal hyperplasia, as well as the sometimes subtle Dr Montoya-Williams cared for the patient and drafted the initial manuscript; Dr Mowitz cared presentation of adrenal insufficiency. To our knowledge, it is also the first for the patient and reviewed and edited the reported case of complex GKD deficiency with the additional finding of manuscript; and both authors approved the fi nal hepatic iron deposition, which may indicate a potential area for exploration manuscript and agree to be accountable for all aspects of the work. regarding the pathogenesis of liver injury and cholestasis seen in cortisol- DOI: https://doi. org/ 10. 1542/ peds. 2016- 1479 related endocrinopathies. Accepted for publication Dec 12, 2016 Address correspondence to Diana Montoya- Williams, MD, Department of Pediatrics, Division of Adrenal hypoplasia congenita (AHC) (DMD), which is then often labeled Neonatology, University of Florida, PO Box 100296, is a rare cause of congenital adrenal complex GKD or Chromosome Xp21 Gainesville, FL 32610. E-mail: dmontoyafontalvo@ insufficiency that often presents deletion syndrome due to the position peds.ufl .edu early in life, with salt wasting and of all 3 loci on the short arm of the X PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, hypoglycemia leading to growth chromosome.2 Isolated GKD can cause 1098-4275). failure and hemodynamic crises. 1 metabolic acidosis and hypoglycemia Copyright © 2017 by the American Academy of It may present similarly to the but is usually asymptomatic and Pediatrics more common congenital adrenal detected incidentally through FINANCIAL DISCLOSURE: The authors have hyperplasia, but has important hyperlipidemia testing, as it causes indicated they have no fi nancial relationships relevant to this article to disclose. clinical distinctions, such as the a pseudohypertriglyceridemia. 3 potential for hyperpigmentation, Complex GKD, however, carries a FUNDING: No external funding. and other signs of much more serious prognosis, as it can POTENTIAL CONFLICT OF INTEREST: The authors hypogonadotropic hypogonadism, lead to life-threatening adrenal crises have indicated they have no potential confl icts of interest to disclose. and associated disorders. AHC can if unrecognized. be autosomal recessive or present as part of a contiguous X-linked To cite: Montoya-Williams D and Mowitz M. recessive genetic syndrome together PRESENTATION Cholestasis and Hepatic Iron Deposition in an with glycerol kinase deficiency (GKD) The case was a 3100-g 6-week- Infant With Complex Glycerol Kinase Defi ciency. Pediatrics. 2017;140(1):e20161479 and Duchenne muscular dystrophy old male infant transferred to our

Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 140 , number 1 , July 2017 :e 20161479 CASE REPORT NICU for further evaluation of his aspartate aminotransferase and and mild , but notably no persistent hyperbilirubinemia, alanine aminotransferase showing hepatomegaly. He also had extremely hypertriglyceridemia, elevated a persistent fivefold elevation dark skin, which the parents reported creatine kinase (CK) levels, and despite discontinuation of parenteral was not present at birth but had transaminitis. He was born at 40 nutrition. He was further noted to developed quickly after birth. The weeks’ gestation by spontaneous have elevated triglyceride levels up remainder of the examination vaginal delivery to a 30-year-old to maximum of 811 mg/dL despite was normal. Laboratories in the gravida 1 para 0 mother who was being fed several different types of first week of admission revealed Group B Streptococcus positive formula. normal electrolytes but continued but otherwise had unremarkable hypertriglyceridemia, cholestasis, Given the continued elevation in prenatal serologies. Apgar scores transaminitis, and CK elevations his bilirubin and transaminases, he were 9 and 9 at 1 and 5 minutes, (Table 1). We investigated for inborn received an extensive gastrointestinal respectively, and birth weight errors of bile acid metabolism by workup, including normal was 2946 g. Mother received sending total and fractionated bile abdominal imaging (ultrasound adequate intrapartum antibiotic acid levels, as elevations of unusual and upper gastrointestinal series), prophylaxis but was diagnosed with bile acids have been associated with normal pancreatic enzyme and chorioamnionitis; thus, the patient severe cholestasis and subsequent ammonia levels, and negative received 48 hours of antibiotics at liver damage. 5, 6 Although our hepatitis serologies. A hepatobiliary birth. He was also noted to have mild patient’s total bile acid levels were iminodiacetic acid scan conducted at jaundice in the first few days of life elevated (>128 μmol/L), his profile 1 month of life revealed no excretion attributed to ABO incompatibility, indicated nonspecific cholestasis of tracer from the liver; thus, a liver although his hemoglobin levels given the predominance of primary biopsy was done, which revealed showed no evidence of hemolysis. bile acids. focal intracellular cholestasis On day of life 5, he became febrile, with giant cell transformation of Over the next 2 weeks, he remained lethargic, and more jaundiced. some hepatocytes and moderately hospitalized working on oral feeds. He developed severe refractory increased iron stores, but no Routine laboratories at 7 weeks of hypotension and respiratory steatosis, fibrosis, necrosis, age revealed hyponatremia (130 failure. Laboratory testing inflammation, or features of biliary mmol/L) and hyperkalemia (8.1 revealed a significant coagulopathy atresia. The hepatic siderosis mmol/L) with normal renal function (international normalized ratio 3.9), raised concerns for neonatal (creatinine 0.18 mg/dL) and good hyponatremia, and hyperkalemia hemochromatosis, a phenotype of urine output on full enteral feeds in the setting of significant oliguria. severe liver disease with extrahepatic and no medications. Although he He was also noted to have signs iron deposition that can result remained hemodynamically stable, of end-organ ischemia with an from various causes. 4 Our patient his ongoing lack of a unifying elevation in his troponins, creatinine, underwent a buccal biopsy to look diagnosis and these laboratory transaminases, and CK levels. He for iron staining and a brain MRI to findings led to an investigation was managed with broad-spectrum look for iron deposition, but these of his adrenal function. Both antibiotics for presumed sepsis, were both normal. He was evaluated his cortisol (2.0 μg/dL) and and with multiple vasopressors and for inborn errors of metabolism aldosterone (<3.0 ng/dL) levels were hydrocortisone for his refractory that can cause liver disease, such as abnormally low. Concurrent plasma hypotensive shock. He received galactosemia, tyrosinemia, or α-1 adrenocorticotropic hormone and intramuscular vitamin K and fresh- antitrypsin deficiency, and was found plasma renin activity levels were frozen plasma transfusions over to have borderline elevated levels of noted to be extremely elevated at several days until normalization of acylcarnitines known to be falsely 3192 pg/mL (normal 5–46 pg/mL) his international normalized ratio. elevated by parenteral nutrition. and 66 ng/mL per hour (normal Otherwise this workup was negative. Extensive infectious workup, for age <37 mg/mL per hour), including bacterial, viral, and fungal Given the persistent laboratory respectively. Combining this evidence studies, remained negative. He slowly abnormalities, transfer to our NICU of adrenal hypofunction with his improved and was weaned from the was requested. On admission, he elevated CK levels, complex GKD was ventilator and all blood pressure was clinically stable, but his weight suspected. The laboratory was asked support, including steroids. All was below the third percentile, to correct his triglyceride levels for laboratory values normalized with down from the 15th percentile serum glycerols, which revealed a the exception of his direct bilirubin, at birth. Examination revealed true triglyceride level within the CK levels, and transaminases, with cryptorchidism, scleral icterus, normal range. Furthermore, glycerol

Downloaded from www.aappublications.org/news by guest on October 1, 2021 e2 MONTOYA-WILLIAMS and MOWITZ TABLE 1 Summary of Abnormal Laboratory Studies After Admission to Our Hospital at 6 Weeks of Age Laboratory Test Range Over the First Week of Admission to Our Hospital Reference Ranges for Age Triglyceride 450–781 mg/dL 30–124 mg/dL Total bilirubin 9.8–11.6 mg/dL <1.2 mg/dL Direct bilirubin 7.2–8.9 mg/dL 0–0.2 mg/dL γ glutamyl transpeptidase 223 U/L 4–120 U/L Aspartate aminotransferase (serum glutamic-oxaloacetic 193–335 U/L 15–60 U/L transaminase) Alanine aminotransferase (serum glutamic-pyruvic transaminase) 97–243 U/L 13–45 U/L CK 4171 U/L to >20 000 U/L 30–170 U/L

TABLE 2 Results of the Comparative Genomic Hybridization Microarray Study for Our Patient Chromosomal Region Minimum Size of Maximum Size of Maximum Boundaries (Base Pair Potential Disease(s) or Gene(s) That May Be Affected Lossa Lossa Coordinates) Associated With This Region ∼ ∼ – Xp21.3p21.1 7683.0 kb 77347.7 kb chrX:25800484 33535137 DMD, GK, IL1RAPL1, NR0B1 Chromosome Xp21 deletion syndrome Online Mendelian Inheritance in Man: 300679 a A minimum size value represents the actual base pair coordinates of the probes detected as a copy number change, whereas a maximum size value includes the gap distances to bordering unaffected probes that may potentially include additional materials involved in the change detected.

kinase levels were confirmed to be indirectly by measuring serum the first week of life was likely his elevated at 4384 μmol/L (normal glycerol levels. 3, 7 When patients first manifestation of his AHC. When 13–66 μmol/L). are also missing either of both an infant presents with symptoms the dystrophin gene and/or the of adrenal insufficiency, clinicians Ultimately, a comparative genomic Nuclear Receptor Subfamily 0, must rightly consider congenital hybridization microarray study was Group B, Member 1 (NR0B1) gene, adrenal hyperplasia, as it has a done, which confirmed an Xp21 the condition is known as complex much higher incidence of 1:5000 to deletion ( Table 2). His mother was GKD or Chromosome Xp21 deletion 1:15 000 compared with 1:140 000 to also found to be a carrier of this syndrome due to the contiguous 1:1 200 000 for AHC.8, 9 Importantly, deletion by fluorescence in situ position of all 3 loci on the short AHC usually presents with normal hybridization study. arm of the X chromosome. 2 Each 17-hydroxyprogesterone levels, Our patient was started on gene deletion contributes to the excluding the most common cause of replacement fludrocortisone phenotype, with the deletion of the congenital adrenal hyperplasia. 10 –12 and hydrocortisone; within 4 dystrophin gene causing weakness In addition, given AHC’s involvement days, his plasma renin activity and muscle breakdown consistent of the entire adrenal gland, it has levels normalized. Over the with DMD, the deletion of the NR0B1 the potential for an Addisonian-like course of the next few weeks, his gene causing AHC due to a deficiency presentation of hyperpigmentation, hyperpigmentation, feeding skills, of the DAX-1 protein and finally, which can help differentiate it from and weight gain also improved and the deletion of the glycerol kinase other forms of adrenal insufficiency. he was discharged from the hospital. gene causing elevated glycerol Our patient was born with light levels.8 When all 3 genes are deleted, brown skin ( Fig 1), which darkened the presentation of this recessive significantly in the first week of life DISCUSSION X-linked condition is more severe and (Fig 2). occurs in the infantile period. Due to GKD can exist alone as an isolated We believe our patient’s persistent the involvement of NR0B1 in gonadal deficiency and may cause a Reye-like direct hyperbilirubinemia with development, cryptorchidism may be syndrome of vomiting, metabolic biopsy-confirmed cholestasis was present, as in our patient, and there is acidosis, and ketotic hypoglycemia also likely related to his AHC. The potential for later hypogonadotropic due to hyperglycerolemia and relationship between cortisol hypogonadism during puberty. 8 glyceroluria. 2 However, it is often deficiency and cholestasis has been asymptomatic and discovered Most patients with complex GKD well-described. 13 Although the incidentally later in life through involving the AHC loci will present mechanism is not well understood, hyperlipidemia testing, given many with an acute adrenal crisis in the it may be related to cortisol’s effect laboratories’ standard methodology first few weeks to months of life. Our on bile formation. In 1 case series of reporting serum triglycerides patient’s presumed septic crisis in of 4 neonates with severe cortisol

Downloaded from www.aappublications.org/news by guest on October 1, 2021 PEDIATRICS Volume 140 , number 1 , July 2017 e3 ACKNOWLEDGMENTS The authors acknowledge the parents of this infant who gave informed consent to describe this patient for a case report and provided photographs.

ABBREVIATIONS AHC: adrenal hypoplasia congenita CK: creatine kinase DMD: Duchenne muscular dystrophy FIGURE 2 GKD: glycerol kinase deficiency Our patient’s pigmentation at the time of NR0B1: Nuclear Receptor FIGURE 1 presentation to our institution at 6 weeks of Subfamily 0, Group B, age. Our patient’s skin pigmentation immediately Member 1 after birth. There have, however, been several deficiency, cholestasis resolved case reports of patients with with hydrocortisone replacement. 13 adrenal insufficiency who were REFERENCES We witnessed this same pattern in found to have increased hepatic 15,16 our patient, whose direct bilirubin iron deposition. In addition, 1. Peter M, Viemann M, Partsch CJ, peaked at 8.9 mg/dL but improved there is at least 1 reported case Sippell WG. Congenital adrenal down to 3.6 mg/dL after replacement of improvement in liver failure hypoplasia: clinical spectrum, experience with hormonal diagnosis, steroid therapy. after corticosteroid replacement for adrenal insufficiency, possibly and report on new point mutations indicating a relationship between of the DAX-1 gene. J Clin Endocrinol Our patient, however, uniquely – these 2 disease processes.17 Given Metab. 1998;83(8):2666 2674 exhibited iron deposition on his liver this literature, it is possible that our 2. Sjarif DR, Ploos van Amstel JK, Duran biopsy. To our knowledge, hepatic patient’s siderosis was related to his M, Beemer FA, Poll-The BT. Isolated siderosis has not been previously adrenal hypofunction and not simply and contiguous glycerol kinase gene documented in any of the reported a manifestation of our patient’s initial disorders: a review. J Inherit Metab cases of isolated AHC, GKD, DMD, – acute hepatic injury. Future efforts to Dis. 2000;23(6):529 547 or complex GKD. It is possible that understand this contiguous deletion 3. Walker AP, Muscatelli F, Stafford AN, his siderosis was related to other syndrome may therefore benefit from et al. Mutations and phenotype in etiologies. For instance, hepatic the exploration of the potential link isolated glycerol kinase defi ciency. Am – siderosis has been documented among adrenal insufficiency, hepatic J Hum Genet. 1996;58(6):1205 1211 in cases of neonatal acute liver iron deposition, and cholestatic liver 4. Feldman AG, Whitington PF. Neonatal 14 ’ failure. Our patient s history of injury. hemochromatosis. J Clin Exp Hepatol. coagulopathy, transaminitis, and 2013;3(4):313–320 direct hyperbilirubinemia during 5. Seki Y, Mizuochi T, Kimura A, et al. his early hypotensive shock episode CONCLUSIONS Two neonatal cholestasis patients indicate that he likely suffered at with mutations in the SRD5B1 least acute hepatic injury; however, It is important for clinicians to (AKR1D1) gene: diagnosis and bile his coagulopathy quickly improved consider AHC and its associated acid profi les during chenodeoxycholic and he never developed episodes of genetic syndromes when evaluating acid treatment. J Inherit Metab Dis. – bleeding, ascites, or hepatomegaly. infants with suspected adrenal 2013;36(3):565 573 Additionally, the liver biopsy did insufficiency. Further studies 6. Heubi JE, Setchell KDR, Bove KE. Inborn not have any of the hepatocyte loss, focused on the relationship between errors of bile acid metabolism. Semin inflammation, or necrosis typically cholestasis and cortisol deficiency Liver Dis. 2007;27(3):282–294 associated with acute liver failure, or are warranted, as they may provide 7. Li R, Keymeulen B, Gerlo E. any cirrhosis or fibrosis indicative of insight into the pathophysiology of Determination of glycerol in chronic liver injury. disorders such as complex GKD. plasma by an automated enzymatic

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