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Novel and Recurrent ACADS Mutations and Clinical Manifestations Observed in Korean Patients with Short-Chain Acyl-Coenzyme a Dehydrogenase Deficiency

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Novel and Recurrent ACADS Mutations and Clinical Manifestations Observed in Korean Patients with Short-Chain Acyl-Coenzyme a Dehydrogenase Deficiency Available online at www.annclinlabsci.org 360 Annals of Clinical & Laboratory Science, vol. 46, no. 4, 2016 Novel and Recurrent ACADS Mutations and Clinical Manifestations Observed in Korean Patients with Short-chain Acyl-coenzyme a Dehydrogenase Deficiency Yoo-Mi Kim1, Chong-Kun Cheon1,*, Kyung-Hee Park2, Sung Won Park3, Gu-Hwan Kim4, Han-WookYoo4, Kyung-A Lee5, and Jung Min Ko6,* 1Department of Pediatrics, Pusan National University Children’s Hospital, Pusan National University School of Medi- cine, Yangsan, 2Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine, Busan, 3Department of Pediatrics, Dankook University College of Medicine, Cheil General Hospital & Woman's Health care Center, Seoul, 4Medical Genetics Center, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, 5Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, 6Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea Abstract. Short-chain acyl-CoA dehydrogenase (SCAD) catalyzes the first step in mitochondrial short- chain β-oxidation, and its deficiency is caused by mutations in the ACADS. We sought to investigate the spectrum ACADS mutations and associated clinical manifestations in Korean patients with SCAD defi- ciency. The study included ten patients with SCAD deficiency from 8 unrelated families as diagnosed by biochemical profile and mutation analyses. Clinical features, biochemical data, growth, and neurodevelop- mental state were reviewed retrospectively. Eight patients were found during newborn screening, and two were diagnosed by family screening. During follow-up ranging from 2 months to 4.5 years, no hypoglyce- mic event was noted, and the development and growth of the patients were normal, except in two siblings. One exhibited hypotonia and gross motor delay, while one girl showed cyclic vomiting until the age of two years. We identified seven different mutations of ACADS. Of these, p.E344G was the most frequent muta- tion with an allele frequency of 50%, followed by p.P55L with 18.8%. p.G108D and four novel mutations were identified: p.L93I, p.E228K, p.P377L, and p.R386H. Korean patients with SCAD deficiency showed heterogenous clinical features and ACADS genotype. Our data contributes to a better understanding of the distinct molecular genetic characteristics and clinical manifestations of SCAD deficiency. Key words: Fatty acid beta-oxidation, Short-chain acyl-CoA dehydrogenase deficiency, ACADS, Newborn screening test. Introduction autosomal-recessively inherited metabolic disorder and has shown a wide clinical spectrum of mani- Short-chain acyl-coenzyme A dehydrogenase (acyl- festation ranging from asymptomatic to severe CoA dehydrogenase, short-chain; SCAD) catalyzes symptoms and signs including hypotonia, failure the first step in mitochondrial short-chain to thrive, developmental delay, ketotic hypoglyce- β-oxidation, and its deficiency (OMIM No. mia, epilepsy, and behavioral disorders [1–4]. 606885) is caused by mutations in ACADS (the gene for acyl-CoA dehydrogenase, short-chain) on Conventionally, a diagnosis of SCAD deficiency chromosome 12q22 [1]. SCAD deficiency is an has been made biochemically through the recogni- tion of increased serum butyryl carnitine (C4) and *These two authors have contributed equally to the work and are co-corresponding authors. Address correspondence to Jung Min Ko urinary excretion of ethylmalonic acid (EMA) M.D., Department of Pediatrics, Seoul National University Children’s and/or methylsuccinate (MS) [1–2]. SCAD defi- Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-769, South Korea; phone: +82 2 2072 3570; fax: +82 2 743 3455; e mail: jmko@snu. ciency is usually confirmed by DNA analysis for ac.kr or Chong-Kun Cheon, M.D., Department of Pediatrics, Pusan National University Children’s Hospital, Pusan National University ACADS, and approximately 60 disease-causing School of Medicine, Geumo-ro, Yangsan-si, Gyeongnam 602- mutations have been reported to date (http://www. 739, Korea; phone: 82 55 360 3158; fax: 82 55 360 2181; e mail: [email protected] hgmd.org/). 0091-7370/16/0400-360. © 2016 by the Association of Clinical Scientists, Inc. Table 1. Clinical, biochemical features, and molecular analysis of ACADS. Fa Sub Sex Current Age at C4 EMA MS Nucleotide change Amino acid change In silico analysis mily ject age diagnosis (µM/L, (nM/ml, (nM/M Allele 1 Allele2 Allele 1 Allele2 Polyphen-2 SIFT <0.93) <14.6) Cr, <8.8) 1 1 M 11 m 10 d 3.14 50.94 7.91 c.1031A>G. c.1130C>T p.E344G p.P377L† 0.999 0.00 2 M 9.2 y 8 y NA 29.14 ND 2 3 F 4.4 y 12 d 1.79 77.92 ND c.277C>A c.682G>A p.L93I† p.E228K† 0.122/0.98 0.00/0.00 3 4 M 4.4 y 40 m NA 107.28 20.28 c.1031A>G c.1031A>G p.E344G p.E344G 5 M 19 m 14 d 1.93 94.54 13.72 4 6 M 18 m 19 d 1.47 23.68 2.76 c.323G>A c.1031A>G p.G108D p.E344G 5 7 M 24 m 36 d 2.26 24.32 ND c.164C>T c.1031A>G p.P55L p.E344G 6 8 M 15 m 18 d 1.69 62.87 6.81 c.164C>T c.164C>T p.P55L p.P55L 7 9 M 9 m 15 d 1.89 206.42 37.07 c.1157G>A c.1031A>G p.R386H† p.E344G 1.000 0.00 8 10 F 70d 50d 1.78 374.62 37.98 c.1031A>G c.1031A>G p.E344G p.E344G †novel variant. Abbreviations: ACADS, acyl-coenzyme A dehydrogenase gene; C4-C, butyrylcarnitine; EMA, ethylmalonic acid; MS, methylsuccinate; NA, not analyzed; ND, not de- tected; SCADD, short-chain acyl-coenzyme A dehydrogenase deficiency. patients we we dict AC quence tion and Analyz re quest). Ge kocytes informed boar action flanking Ge patients. Na Mo Ho Ho centers ye findings mental clinical urine Di studies analyses in eight Pa Ma deficiency been determine high eral biochemical mutations been 5–7]. an for Be tial AC ctly ars. agnosis this tients cause rmany). nomic tional appr spital). spital assessed ADS lecular conducted terials risk elev ds the ADS Se analysis patients families—eight some EMA re The lev with Ho er quencing study Su (PCR) of ’ we in courses, re scales por opriate functional using ated with and re (NCBI els included most par Un and (A DNA mutations sults consent bsequently we of and re data . Ko Ya gions analysis Te and no ted debate pplied the the and of ents iv associated SCAD fr and ngan molecular ve re re featur n lack ve ersity C4 om we biochemical a molecular tr we with ne having EMA a r, we AC Se was [7–9]. l same candidate molecular Me Ac and we ospectiv Analysis DNA re (P and clinical missense SCAD to re wborn oul re was Ma ADS Pu re measuring of cession impact re Bi usan as in deficiency es extracted of Childr thods administer , compar collected main specific re analyz bo osystems, san PCR rc a and amplified 50 to obtained primers in Ko AC sults Na analysis long-term h This ys neur isolation coding with ely Na whether re re Ko healthy 2009 patients deficiency softwar ADS. analyses Na tional MS. en and No of alterations an vie pr for symptom tional ed e of spectr pr re re ’s tional ological study oducts no primers fr w . SCAD fr vie neur was ser an ofile. clinical Ho ed NM_000531.5). two biochemical om using ne with to of om ex Clinical fr by Fo ve The of e, we um om Un patients kit ons contr spital wborn De l AC until ster based Un SCAD um of found the peripheral polymerase pr oto amino girls—w ve two Ho d. was institutional we iv Te established deficiency cember re ognosis, both ADS a using (Qiagen, rsion iv AC lev and (av ersity patients. De symptoms xic spital City ols. n mains re of fr ersity outcomes 3130xl appr clinical the on manifestations, els ADS conducted ee, ailable patients scr nv sequenced . by their acid deficiency the par with effects , Bi In 5.2. two biochemical er and er of ov age eening CA, 2015. ther and scr blood ochemical Childr Childr e ents a addition, fr ed and chain AC dev changes, enr C4 He intr genetics Ge Wr in om SCAD The To eening poten human genetic of on re muta e USA) Se ADS silico elop of lden, hav fr netic olled itten vie 36 onic sev and and pr leu- and has fiv en en om oul the [1, di- re re se- all to e- 1 w is ’s ’s e e - - - - - - Table 2. Clinical outcomes of patients with short-chain acyl-CoA dehydrogenase deficiency. Family Subject Current Ht, cm Wt, kg BMI, kg/m2 HC, cm Symptoms Carnitine Medication 36 age (SDS) (SDS) (SDS) (SDS) Free Total 2 (24-66 µmol/L) (28-84 µmol/L) 1 1 11 m 78 (1.57) 10 (0.62) 16.44 46.5 Normal development 47.32→46.49 57.1→54.5 Riboflavin Ann 2 9.2 y 136 (0.56) 44.5 (1.78) 24.06 (1.88) NA Normal development ND ND al s 2 3 4.4 y 112.7 (2.61) 22 (2.44) 17.32 (1.25) 52.5 (1.8) Recurrent vomiting, 30.3→38.5 36→49.36 Riboflavin of Metabolic acidosis Cl 3 4 4.4 y 106.1 (0.33) 16.7 (–0.27) 14.83(–0.72) NA Poor feeding, fatigue, 42.08 50.67 Riboflavin in hypotonia ic 5 19 m 84 (0.07) 10.9 (–0.66) 15.45 45.5 (–0.67) Poor feeding, fatigue, 57.67 73.44 Riboflavin al hypotonia, speech delay & 4 6 18 m 87.5 (1.34) 13.3 (1.29) 17.37 NA Normal development ND ND La 5 7 24 m 90.7 (0.82) 14 (0.87) 17.02 (0.07) NA Normal development 47.5 54.99 Riboflavin bor 6 8 15 m 81.6 (0.44) 13 (1.63) 19.52 NA Normal development 50.2 63.7 Riboflavin at or L-carnitine y 7 9 9 m 70.3 (–1.17) 8.0 (–1.35) 16.18 NA Normal development ND ND Riboflavin Sc L-carnitine ie nc 8 10 70d 57(0.14) 4.8(-0.88) 14.77 37.5(-0.01) Normal development 62.9 74.3 Riboflavin e, vo Abbreviations: Ht, height; Wt, weight; BMI, body mass index.
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