DE LA SALLE UNIVERSITY – DASMARIÑAS

Medical Biology

DBB-B, 4115 West Ave, Dasmariñas, Cavite

Amino Acid Metabolic Disorders

In Partial Fulfillment

of the Requirements in Biomolecules Lecture

S.Y. 2020-2021

Submitted by:

RONGAVILLA, John Kenneth C.

SUPNET, Genghis Khan M.

SY, Jewel May G.

UNSO, Denise M.

URBANO, Renee Louise C.

Medical Biology 23

Submitted to:

Dr. Lolibeth Figueroa

February 03, 2021

 I. OVERVIEW OF AMINO ACID METABOLISM DISORDER
Amino acid is one of the building blocks of life. They play a vital role in our bodies both
as building blocks of proteins and as intermediates in metabolism. Each amino acid is synthesized
into important molecules in the body such as neurotransmitters, hormones, pigments, and oxygen-
carrying molecules. When the body has a problem in terms of breaking down certain amino acids,
it might lead to Amino acid metabolic disorders. These are a group of rare inherited metabolic
disorders that include phenylketonuria (PKU) and maple syrup urine disease. These problems may
cause a buildup of harmful substances in the body that can lead to serious health problems and
sometimes, death.

Amino acid metabolic disorders are caused by the body’s inability to detoxify the by-
product of amino acids (ammonia) through the urea cycle. These disorders are autosomal recessive,
and all may be diagnosed by analyzing amino acid concentrations in body fluids. In most hereditary
metabolic disorders, both parents of the affected child carry a copy of the abnormal gene. Because
usually two copies of the abnormal gene are necessary for the disorder to occur, usually neither
parent has the disorder. Some hereditary metabolic disorders are X-linked, which means only one
copy of the abnormal gene can cause the disorder in boys. A baby who is born with one may not
have any symptoms right away. Because the disorders can be so serious, early diagnosis and
treatment are critical. Newborn babies get screened for many of them, using blood tests.
Treatments may include special diets, medicines, and supplements. Some babies may also need
additional treatments if there are complications.

II. AMINO ACID METABOLIC DISORDERS

Overview of Maple Syrup Urine Disease

Clinical Description

Maple syrup urine disease also known as MSUD, BCKD Deficiency, Branched-Chain
Ketoacid and Dehydrogenase Deficiency is a rare, inherited metabolic condition that is
characterized by maple syrup urine odor. In MSUD, the body has trouble breaking down proteins,
which is made up of a chain of smaller units of amino acids. Our body changes amino acids into
other substances with the help of enzymes. Individuals with MSUD have a deficiency in Branched-
Chain Ketoacid Dehydrogenase (BCKAD), an enzyme encoded by four genes and leads to
dysfunction of branched chain amino acid namely Leucine (LEU, L), Isoleucine (ILE, I), and
Valine (VAL, V) because they cannot be broken down. Maple syrup urine odor is also caused by
isoleucine metabolite. Because there’s a dysfunction in branching amino acid and metabolism,
there’s an increase in BCAA that leads to inhibition of the large neutral amino acid (tyrosine and
tryptophan) into the brain. Reduction of these amino acids results in reduction of synthesis of
dopamine and serotonin.

Clinical Characteristics

There are several sub-types of MSUD, the classic, intermittent, intermediate, thiamine
responsive and E3 deficient. The most common type includes classic MSUD, intermittent MSUD
and intermediate MSUD.

Classic MSUD is the most common type. It is represented by BCKDH activity level of less
than 3 percent. Because it is so severe, the signs and symptoms are present within 48 hours of
birth. The signs and symptoms include ketonuria, irritability, poor feeding, lethargy, vomiting and
dystonia. Eventually a baby will develop seizures, apnea, and cerebral edema. It can also have
metabolic-intoxication-episodes, and these episodes are due to the increased endogenous protein
catabolism due to infection, injury, fasting, or exercise. Also, these episodes are characterized by
epigastric pain, vomiting, anorexia, and muscle weakness.

The next subtype is the intermittent MSUD, it is the second most common type and it is
represented by a BCKDH level activity of 5-8 percent. It is characterized by neurologic impairment
and developmental delay. But individuals with intermittent subtypes have a normal growth and
development. During the episodes of Catabolic stress, they present with ketoacidosis. They can
also have issues with recurrent otitis media and they can get ataxia, lethargy, seizures and coma,
typically during catabolic stress episodes.

In the Intermediate MSUD, this is caused due to the mutation in E1-alpha subunit of
BCKDH enzyme and what happens is, the activity level is generally higher in this subtype of
MSUD and it is approximately 3-30 percent. Onset of symptoms can occur at any age. Generally,
there is a later presentation of this condition when an individual has higher BCKDH activity levels,
so if they’re around 30 percent of BCKDH activity level, they won’t present until later in life. The
signs and symptoms of Intermediate MSUD include acute neurological symptoms including
irritability, dystonia, developmental delay, and seizures. So intermediate MSUD is the least severe
form and it can occur at any age.

Genetic Counseling

MSUD is a condition of autosomal recessive inheritance and affects both men and women
equally. Autosomal recessive inheritance is a way a genetic trait or condition can be passed down
from parent to child. MSUD is also rare, about one in every 200,000 (1/200,000) babies in the
United States is born with MSUD

An autosomal recessive disorder means two copies (one from each parent) of an abnormal
gene must be present in order for the disease or trait to develop. This disorder is usually passed on
by two carriers. Their health is rarely affected, but they have one mutated gene (a recessive gene)
and one normal gene (a dominant gene) for the condition. Two carriers have a chance of 25%
having an unaffected child with two normal genes (left), a chance of 50% having an unaffected
child who also is a carrier (middle), and a 25% chance of having an affected child with two
recessive genes (right).

Figure 1. Autosomal Recessive Inheritance

Table 1. Mode of Inheritance of MSUD

MODE OF INHERITANCE

RISK TO FAMILY MEMBERS

Parents of a proband Siblings of a proband

● Parents of affected child are obligate ● At conception, each sibling of affected

heterozygotes (carriers) of one individual has a chance of 25% being
pathogenic variant BCKDHA, affected, a 50% chance of being an
BCKDHB, or DBT asymptomatic carrier, and a chance of
● Carriers are asymptomatic and are 25% being unaffected and not a carrier
not at risk of developing MSUD ● Carriers are asymptomatic and are not at
risk of developing MSUD

Offspring of a proband Other family members

● The offspring of an individual with ● Each sibling of the proband's parents is at

MSUD are obligate heterozygotes risk of being a 50% carrier of a pathogenic
(carriers) for pathogenic variant variant BCKDHA, BCKDHB, or DBT.
BCKDHA, BCKDHB, or DBT
 CARRIER (HETEROZYGOTE) DETECTION

Molecular Genetic Testing Biochemical Testing

● Carrier testing for relatives at-risk ● Quantitative plasma amino acids and
requires prior identification of the fibroblast enzymatic analyses are not
pathogenic variants BCKDHA, indicated for detection of heterozygotes
BCKDHB, or DBT in the family (carriers)

CARRIER (HETEROZYGOTE) DETECTION

Molecular Genetic Testing Biochemical Testing

● Once the pathogenic variants ● If only one or neither pathogenic variant

BCKDHA, BCKDHB, or DBT have
been identified in an affected family
member, prenatal diagnosis and
preimplantation genetic testing for a
pregnancy at increased risk for
MSUD are possible
BCKDHA, BCKDHB, or DBT is known
within a family, BCKD enzyme activity
can be measured from cultured
amniocytes obtained by amniocentesis
(usually performed at 15-18 weeks'
gestation) or chorionic villus cells
obtained by chorionic villus sampling
(usually performed at 10-12 weeks'
gestation)
 RELATED GENETIC COUNSELING ISSUES

Family planning DNA banking

● Before pregnancy is the optimal time ● It is appropriate to offer genetic

for determination of genetic risk, counseling (like discussion of
clarification of carrier status, and potential risks to offspring and
discussion of the availability of reproductive options) to young
prenatal testing adults who are affected, carriers, or
even the ones at risk of being carriers

Pathophysiology of Maple Syrup Urine Disease

Branched Chain Amino Acids Metabolism

Branched-chain amino acids involves three essential amino acids known to be leucine,
isoleucine, and valine which are found in protein-rich diets and have an important mediation
effects on the functionality of protein synthesis, glucose homeostasis, anti-obesity, and nutrient-
sensitive signaling pathways such as phosphoinositide 3-kinase/protein kinase B/mammalian
target of rapamycin (PI3K/AKT/mTOR) signal pathway. BCAA then, are known to be the
biomarkers in the prediction of obesity, IR, T2DM, and CVDs outcomes.

In the BCAA catabolic pathway, leucine, isoleucine, and valine undergo transamination
catalyzed by branched-chain aminotransferase that requires ketoglutarate for the production of the
α-ketoacids, α-ketoisocaproic acid, α-keto-β-methylvaleric acid and α-ketoisovaleric acid. All the
intermediates will then proceed to oxidative decarboxylation in the catalyzation by the branched-
chain α-ketoacid dehydrogenase complex.
 Figure 2. BCAA Mechanism

According to Brosan, M & Brosan, J. (2006), The metabolism of BCAAs presents several
novel features: the catabolism of three amino acids controlled by a common flux-generating step,
their catabolic disposal largely in skeletal muscle, their circulating concentration influencing the
brain uptake of precursor amino acids for neurotransmitter synthesis, and the regulation of protein
synthesis in variety of tissues.

The first step of BCAA catabolism involves the conversion of BCAAs hydrophobic amino
acids into their relevant α-ketoacids by branched-chain aminotransferase within the mitochondria
where the majority of the said process is likely to occur not in the liver but in the skeletal system
due to the expectation that the mitochondrial activity found in humans are widely distributed with
particularly high expression in the colon, kidney, and skeletal muscle rather than the liver as it
manifests low in expression. This then leads for the BCAAs to be catabolized extra-hepatically.
 Second step of BCAA catabolism involves BCKAD complex to initiate oxidative
decarboxylation of α-ketoacids resulting for the conversion of α-ketoacids into acetoacetate,
acetyl-CoA, and succinyl-CoA as seen in the diagram. The BCKAD complex is made up of several
components, including E1α and E1β, E2, and E3. This will manifest as an increase in BCAA levels
due to pathogenic defects caused by MSUD and will likely lead to the dysfunction of the immune
system, skeletal muscle, and central nervous system. Excessive amounts of BCAAs build-up
catalyzed by the MSUD can severe tissue damage if not given treatment immediately.

Effects of Enzyme Deficiencies by Branched-chain α-ketoacid Dehydrogenase

Abnormalities in the production of BCAA is caused by the malfunctional of the BCKAD
which leads to pathogenic defects in its complementary components due to MSUD. When the
enzyme becomes deficient, the BCAA will dramatically increase due to the decreased biallelic
pathogenic variants in the catalytic components of the BCKAD, that is responsible for the initiation
of oxidative decarboxylation of α-ketoacids in the BCAA catabolism. The enzyme deficiency will
likely cause a manifestation of the disorder in glutamate synthesis leading to various neurological
problems in patients.

Metabolism of the BCAA will not be able to maintain glutamate level, leading to an
excessive build-up and may highly affect the functionality of tissues vulnerable to the disorder. As
the accumulation of leucine is highly neurotoxic, elevated levels of the amino acid will also likely
to influence the water homeostasis within the subcortical gray matter, leading to a swelling within
the brain, and alteration of nitrogen homeostasis, further depleting glutamate levels, increased
oxidative stress, and intervene with other important amino acids within the CNS such as those the
is relevant to protein signaling.

Diagnosis of MSUD
Symptoms may vary on the degree of enzyme activity, severity, and the occurrence of
Maple Syrup Urine Disease correlated to a patient’s age. These symptoms will then be segregated
by the four subtypes of the said inherited metabolic disorder known to be: Classic MSUD,
Intermediate MSUD, Intermittent MSUD, and Thiamine-respond MSUD.
Signs and Symptoms
Common Symptoms which can be found on all four types of Maple Syrup Urine Disease:
● Urine, sweat, or earwax smelling like maple syrup or burnt sugar (from which the name of
the disorder is derived)
● Dramatic changes in muscle tone
● Abnormality in the movements of muscle, spasms that leads to a backward arching of the
head, neck, and spine
● Delay in the overall development of the patient
● Frequent seizures, convulsions, respiratory failure will likely occur as the progression of
the said condition continues; may lead to coma
● A visible manifestation of the patient being sluggish/slow/tiredness and weakness
● Difficult in feeding, loss of appetite, vomiting, irritability

Classic MSUD
As the newborn starts to be fed by protein, the first visible manifestation of the disease will likely
be observed:
● Difficulty in feeding
● Weakened or Disorganized Suck/Swallow/Breathe
● Loss in weight
● Hyperpronated cries
● Urination with an odor similar to maple syrup

Classic MSUD is the most severe type and is the most common of all subtypes. Development of
symptoms will likely occur within the first three days of birth.

Intermediate MSUD
Patients with intermediate cases of MSUD have existing symptoms that typically appear
in children between the ages of 5 months and 7 years. BCKAD enzyme activity is present but less
severe than the classic form, where the majority of individuals are capable of tolerating higher
amounts of leucine compared to classic MSUD. But can dramatically drop especially when
symptoms are nearly identical to the classic type, indicating the severity of the patient’s condition.
Intermittent MSUD
Patients with Intermittent MSUD have reduced BCKAD enzyme activity which may occur
not until the first or second year of life. Symptoms are often episodic and likely to appear during
illness, fasting, or periods of high protein consumption while can tolerate higher levels of three
amino acids than those with classic MSUD.

Thiamine-responsive MSUD
This subtype of MSUD responds to treatment in high dosage of vitamin B1 (thiamine)
accompanied by a restricted diet. With this form, decrease in symptoms when administered by
thiamine will be manifested.

Table 2. Clinical Phenotypes of Maple Syrup Urine Disease

% with
Biochemical Normal
Type Age of Onset Clinical Features
Signs BCKD
Activity
• Maple syrup odor of
cerumen
• Poor feeding
• ↑ BCAAs in
• Irritability, lethargy plasma
• Opisthotonus • ↑ plasma
alloisoleucine
• Focal dystonia
Classic Neonatal 0%-2%
• ↑ BCKAs in
• "Fencing," urine
"bicycling"
• Ketonuria
• Obtundation, coma
• Central respiratory
failure

• Maple syrup odor of Similar to

cerumen classic phenotype,
Intermediate Variable • Poor growth though 3%-30%
quantitatively less
• Poor feeding severe
 • Irritability
• Developmental
delays
• Encephalopathy
during illness

• Normal
• Normal early BCAAs when
growth & well
development
• Similar to
Intermittent Variable • Episodic classic 5%-20%
decompensations biochemical
that can be severe profile during
illness

Improvement of
leucine tolerance
Thiamine- Similar to & biochemical
Variable 2%-40%
responsive intermediate phenotype profile
w/thiamine
therapy
Data taken from: Strauss KA, Puffenberger EG, Carson VJ. Maple Syrup Urine Disease. 2006 Jan
30 [Updated 2020 Apr 23]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews®
[Internet]. Seattle (WA): University of Washington, Seattle; 1993-2021. Available fr om:
https://www.ncbi.nlm.nih.gov/books/NBK1319/

Management of Maple Syrup Urine Disease

Without treatment, brain damage can occur. This can cause spasticity (intellectual
disabilities). Some babies become blind. If not treated, most babies with classic MSUD die within
a few months.

Treatment for MSUD

The doctor of a child with MSUD will work with a metabolic doctor and dietician.
Immediate treatment is needed to prevent intellectual disabilities and serious medical problems.
Most children need to eat as much as a very low-protein diet and drink a special medical formula.
They should start the diet and the formula as soon as they know their child has MSUD.
The following treatments recommended for children with MSUD:

1. Medical Formula

In addition to a low-protein diet, children are often given a special medical formula as a
replacement for milk. This formula gives them the nutrients and protein they need while helping
to keep their BCAA levels in a safe range.

Note: Their metabolic doctor and dietician will tell them what type of formula is best and how
much to use

2. Low branched-chain amino acids diet

The diet is made up of foods that are very low in the BCAAs which are found in protein.
They will avoid foods that are high in protein like cow’s milk, regular formula, meat, fish, cheese
and eggs. Others like regular flour, dried beans, nuts, and peanut butter have BCAAs and must be
avoided or strictly limited.

Many vegetables and fruits have only small-scale amounts of the BCAAs and can be eaten
in carefully measured amounts.

There are other medical foods that are made especially for people with MSUD and they are
special low-protein flours, pastas, and rice.

Lifetime treatment with the MSUD diet is necessary. When people don’t follow the diet,
they are at risk for episodes of metabolic crisis.

3. Supplements

“Thiamine-responsive MSUD” is a rare type of MSUD and children can often be helped
by thiamine supplements. Some children with classic MSUD may also benefit from thiamine.

Note: Approval of a doctor is necessary in taking thiamine supplements.

4. Tracking BCAA levels

Children with MSUD will have regular blood tests to measure amino acid levels. The diet
and formula may need to be adjusted based on blood test results.

5. Call your doctor at the start of any illness

For a child with MSUD, even minor illness can cause a metabolic crisis. In order to prevent
such problems, call their doctor right away when they have any of the following:

● poor appetite
● low energy or extreme sleepiness
● Vomiting
● an infection or illness
● a fever
● behavior or personality changes
● difficulty walking or balance problems

A Child with MSUD needs to eat more carbohydrates and drink more liquids during any
illness – even if they’re not hungry – or they could have a metabolic crisis. A Child who is sick
may not want to eat. If they can’t eat, or if they show signs of metabolic crisis, they may need to
be treated and handled in the hospital.

6. Liver transplantation

One optional treatment for people with MSUD is a ‘liver transplant surgery’. The BCKAD
enzyme that causes MSUD is located in the liver. Hence, some children with MSUD have had
liver transplantation surgery (liver removal and replacement with a donor liver) to treat their
MSUD symptoms.

Liver transplantation is a major surgical procedure and has some risks. People who have
had a liver transplant must take medication for a lifetime to prevent their body from rejecting the
donor liver. However, liver transplantations that are successful cures people of their MSUD
symptoms.
Note: Many factors must be contemplated before surgery and this option should be discussed very
thoroughly with child’s physicians

Their dietician can create a food plan that contains the right amount of protein, nutrients, and
energy to keep your child healthy.

Attached here is a daily treatment routine in individuals with MSUD:

Table 3. Routine Daily Treatment in Individuals with Maple Syrup Urine Disease

Age Principle/Manifestation Treatment Consideration/Other

Leucine tolerance for

BCAA-free powder formula neonates is 65-85
mg/kg/day

Leucine restriction, • Breast milk or

titrated to leucine regular infant
formula can be
tolerance Natural protein as a source of used as a natural
protein source.
essential & nonessential amino
• For infants
Neonate/ acids: 2-3 g/kg/day
w/classic MSUD,
Infant breast milk should
be expressed &
quantified.

• Record of BCAA
supplement intake
maintained by
Maintenance of adequate 10 mg/mL solutions of
parents
isoleucine & valine isoleucine, valine, & leucine in
• Dried blood spots
supplements distilled water by overnight mail
for monitoring of
amino acid
concentrations
 Leucine restriction, Leucine tolerance: In persons w/classic
titrated to leucine MSUD (0%-2%
• Children: 20-40 mg/kg/day
tolerance enzyme activity)
• Adults:10-15 mg/kg/day

• Isoleucine
supplements can
periodically be
suspended based
on plasma amino
Maintain a plasma leucine-to- acid monitoring,
but continuous
Maintenance of adequate valine concentration ratio
Child/ valine
isoleucine & valine (mol:mol) of 0.5 or fewer and supplementation
Adult is
supplements a leucine-to-isoleucine ratio of
recommended. 5
approximately 2.0
• Continuous valine
fortification is
directly related to
long-term
intellectual
outcome.

Standard psychostimulant &

Neuropsychiatric
antidepressant medications as ————————
morbidity
needed

Nutrient Intake per

Nutrient Intake per kg-day
Normal age- & weight- kg-day depends on
depends on the nutrient itself
adjusted energy intake the nutrient itself and
and age
All ages age

Addressing ↑ Fundoplication, gastrostomy, Adequate provision

energy/caloric demands or jejunostomy to address of information &
 feeding issues as needed in education to parents,
neurologically affected persons patients, & caregivers

• Physical therapy
Gross motor delay ————————
• Aggressive rehabilitation
therapy
Data taken from: Strauss KA, Puffenberger EG, Carson VJ. Maple Syrup Urine Disease. 2006 Jan
30 [Updated 2020 Apr 23]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews®
[Internet]. Seattle (WA): University of Washington, Seattle; 1993-2021. Available fr om:
https://www.ncbi.nlm.nih.gov/books/NBK1319/

If MSUD is not treated

If not treated, other symptoms can occur:
● episodes where muscle tone alternates between being rigid and floppy
● swelling of the brain
● Seizures
● metabolic acidosis – high levels of acidic substances in the blood
● coma, sometimes leading to death
Symptoms of a metabolic crisis often happen:
● starvation: after going too long without food
● during illness or infection
● during stressful events (e.g. surgery)

With punctual and lifetime treatment, children with MSUD often have healthy lives with
normal growth and development. Early treatment can help avert brain damage and intellectual
disabilities. However, children with MSUD are at increased risk to have attention deficit
hyperactivity disorder also known as ADHD, anxiety and depression even if they have had a liver
transplant. The reasons for this are not well acknowledged at this time.

Even with treatment, some children with MSUD still develop swelling of the brain or have
episodes of metabolic crisis. Children who have frequent metabolic crises may develop permanent
brain damage. This can cause lifetime learning problems, intellectual disabilities, or spasticity.
Overview of Homocystinuria

Clinical Description

Homocystinuria is a rare metabolic condition characterized by the inability of the specific

enzymes to metabolize an amino acid called methionine and its metabolites, leading to excessive
buildup in the blood and urine. There are three forms of homocystinuria called type 1, 2, and 3,
which are distinguished based on the deficiency of any of the two enzymes and one cofactor
involved in the conversion of the essential amino acid to another amino acid. In homocystinuria
type 1, methionine metabolism is inhibited by the deficiency of cystathionine beta-synthase that
converts homocysteine into cysteine. The homocystinuria type 1 is also further divided into 2
phenotypes: Vitamin B6 responsive and vitamin B6 non-responsive. These phenotypes refer to the
responsiveness of vitamin B6 to the cystathionine beta-synthase. Homocystinuria type 2 is the
deficiency of cobalamin cofactor which is needed by methionine synthase to function and convert
the homocysteine into methionine. Furthermore, homocystinuria type 3 refers to the deficiency of
methylenetetrahydrofolate reductase that also inhibits the conversion of homocysteine to
methionine.

Table 2. Clinical Phenotypes of Homocystinuria

Types of Homocystinuria Enzyme/cofactor deficiency

Homocystinuria-I Cystathionine beta-synthase

 Homocystinuria-II Cobalamin

Homocystinuria-III Methylenetetrahydrofolate reductase

Clinical Characteristics

The most common form of homocystinuria is caused by the cystathionine beta-synthase

deficiency. There are four organ systems affected by the homocystinuria type 1: ocular, vascular,
central nervous, and skeletal.

Early onset symptoms in the ocular system is lens dislocation at the age of two years old
and further affects individuals at the age of 10. Other ocular abnormalities in homocystinuria Type
1 includes severe myopia, glaucoma, optic atrophy, and retinal detachment.

Another common symptom of homocystinuria type 1 is vascular disease in a form of

thromboembolism. Thromboembolism refers to the obstruction of blood vessels by blood clot.
This leads to the major cause of high mortality rate and early death of individuals at any age.

Cognitive impairment is also a common symptom of homocystinuria type 1. Several

studies suggest that the average IQ of an untreated homocystinuria Type 1 ranges between 10 to
138. Furthermore, individuals with vitamin B6 responsive have higher mean IQ than those with
vitamin B6 non-responsive.

In the skeletal system, symptoms include osteoporosis and other joint abnormalities that
resemble Marfan Syndrome.
 Other types of homocystinuria also exhibit the same signs and symptoms as the
homocystinuria Type 1 but with severe conditions such as megaloblastic anemia and
hypomethionemia.

Genetic Counseling

Homocystinuria is inherited in an autosomal recessive manner that can affect both males
and females equally. This causes the genetic mutation of homocystinuria to be passed down to the
next generation by inheriting one copy of a mutated gene from each parent. Otherwise, a newborn
that only inherits one mutated gene is a carrier of the disorder. In a mathematical concept, each
individual has a 25% chance of being infected, a 50% chance of being an asymptomatic carrier,
and a 25% for being unaffected and not a carrier of the disorder.

Pathophysiology of Homocystinuria

Methionine Metabolism

Methionine is a sulfur-containing amino acid found in protein-rich foods such as meat, fish,
and dairy products. Methionine is also the precursor of other sulfur-containing amino acids like
homocysteine, cysteine, and taurine.

In the Methionine cycle, methionine is added with adenosine from the ATP by methionine
adenosyltransferase, forming S−adenosyl methionine (SAM). The removal of the methyl group
from SAM results in the formation of S−adenosyl homocysteine (SAH), which is immediately
converted into homocysteine by removing the adenosine molecule from it. The homocysteine can
be then used in the three other metabolic pathways.
 Figure 3 Methionine Metabolism Cycle

The first and major pathway of methionine metabolism is the transsulfuration pathway,
which converts the homocysteine into cysteine. The process starts with the both homocysteine and
serine being irreversibly metabolized into cystathionine via the cystathionine beta-synthase (CBS)
along with its cofactor, pyridoxine (vitamin B6). Cystathionine is then cleaved by the cystathionine
gamma-synthase (CYL) with Pyridoxine to form Cysteine. Cystine can be further converted into
inorganic sulfate and other amino acids such as taurine and glutathione.

The second pathway of the methionine metabolism is the folate-dependent remethylation

pathway. In the folate-dependent remethylation pathway, the methyl group from 5-methyl-
tetrahydrofolate is transferred to homocysteine by the cobalamin-dependent (Vitamin B12)
methionine synthase, producing both methionine and tetrahydrofolate (THF). The THF is then
catalyzed by the serine hydroxymethyltransferase (SHMT) to 5,10-methylenetetrahydrofolate.
This process removes the extra carbon from the THF and transfers it to Serine to become glycine.
The 5,10-methylenetetrahydrofolate will be converted again into 5-methyl-tetrahydrofolate by
Methylenetetrahydrofolate reductase (MTHFR) and so forth.
 The third and the last pathway is the folate-independent remethylation pathway. Betaine
(TMG) is another source of methyl group that is transferred to homocysteine via betaine
homocysteine methyltransferase (BHMT), producing methionine.

Depending on the transmethylation and remethylation homeostasis, each pathway has their
certain regulator to stabilize or lessen the production of certain products. For example, excess
methionine activates the production of SAM, which also activates the CSB and inhibits MTHFR
and BHMT, causing the homocysteine to be irreversibly metabolized into cysteine. On the other
hand, the presence of low amounts of methionine in the bloodstream triggers the MTHFR and
BHMT to constantly convert homocysteine to methionine, causing the CBS to be inhibited since
there is no production of SAM.

The combined activities of these three-interrelated pathways determine the production of

methionine and its metabolites. Therefore, any disruption within these pathways results in the
buildup of homocysteine, leading to homocystinuria and other related conditions.

Effects of Enzyme Deficiencies in the Metabolic Pathways of Methionine

The accumulation of homocysteine in the blood is caused by the deficiency of any enzymes
from the transsulfuration and folate-dependent remethylation pathway. Theoretically,
homocystinuria could be the result of any of these pathways due to the mutation of the gene that
regulates the enzyme or a defected cofactor that could no longer be used.

As discussed earlier, the common type of homocystinuria is caused by the cystathionine

beta-synthase deficiency, which impairs the production of cysteine and further accumulates
homocysteine as well as methionine in the bloodstream. Depending on the genetic mutations in
the CBS gene, it can lead to impaired function or inactivation of this enzyme. This results in the
two phenotypes of homocystinuria: Vitamin B6 responsive and Vitamin B6 non-responsive.
Furthermore, the vitamin B6 non-responsive homocystinuria is more severe than the vitamin B6
responsive homocystinuria due to the fact that the non-responsive can no longer be treated with
pyridoxine intake.

The folate-dependent remethylation pathway is also affected by the deficiency of

methylenetetrahydrofolate reductase (MTHFR) and cobalamin (vitamin b6) cofactor. Similar to
CBS, genetic mutations in the MTHFR can lead to impaired functions or inactivation of this
enzyme that leads to the lack of 5-methyl-tetrahydrofolate, a metabolite of folic acid. In addition,
deficiency of the cobalamin is the result of the mutation in the transcobalamin II (TCN2) that
produces transcobalamin, a transport protein for cobalamin. Thus, the lack of the 5-methyl-
tetrahydrofolate and cobalamin inhibits the function of methionine synthase (MTR). The following
table summarizes the effects of enzymes and cofactor deficiency in the body.

Table 4. Effects of the Enzyme and Cofactor Deficiency in the Body

Amino Acids CBS MTHFR cblC

Methionine
↑↑ ↓↓ ↓↓

Homocysteine
↑↑ ↑↑ ↑↑

———————— ————————
Cysteine
↓↓

Diagnosis of Homocystinuria

Signs and Symptoms

Individuals with homocystinuria may present a wide range of signs and symptoms
depending on the age and the organs involved. The following conditions may be observed:

● Dislocated lens
● Nearsightedness
● Development of blood clots
● Osteoporosis or brittle bones
● Intellectual disability
Other less common variations of the disorder also include:

● Seizures
● Behavioral problems
● Small head and brain size
● Joint abnormalities that resembles Marfan syndrome
● hypopigmentation of the skin and hair
● Other symptoms involving the heart and the blood such as megaloblastic anemia and heart
diseases

In addition, homocystinuria is usually asymptomatic in the infants. If left untreated, these infants
may develop severe symptoms such as mental retardation, severe thromboembolism, and a
marfanoid appearance.

To prevent further cases of homocystinuria, different diagnostics tests are used to determine the
early signs of gene mutations and the elevation of Homocysteine and Methionine.

Newborn Screening

Newborn screening is a state of public health services in the United States that ensures all
newborns are screened for certain serious conditions at birth. It also allows the doctors to start the
treatment for those who have serious conditions before the severe symptoms appear.

Homocystinuria Type 1 can be detected by screening the newborn’s blood spot specimen
for hypermethioninemia through tandem mass spectrometry (MS/MS).

If the initial screening test results exceed the required level of methionine, a follow-up
testing is required. This may be:

1. A dried blood specimen submitted to the newborn screening program; or

2. Quantitative plasma amino acid and plasma homocysteine analysis as suggested by the
American College of Medical Genetic.
Molecular Gene Testing

Another diagnostic test is the molecular gene testing. Molecular gene test is the study of
single or multiple genes to identify any variations or mutations that lead to a specific genetic
disorder.

There are two methods used in molecular gene testing: gene-targeted deletion/duplication
analysis and multigene panel.

Depending on the number of pathogenic variants, sequence analysis can be performed first
to determine its features, function, structure, or evolution. and followed by the gene-
deletion/duplication analysis.

The gene-targeted deletion/duplication analysis can only be used if only one or no

pathogenic variant is found. Otherwise, a multigene panel is used to test multiple genes of interest
associated with the clinical phenotype.

Enzyme Activity in Cultured Fibroblasts

An analysis of the enzyme is performed when the molecular genetic test fails to identify
the pathogenic variants in the said enzyme. In the case of homocystinuria type 1, cystathionine
beta-synthase can be measured or analyzed in fibroblast or plasma. However, this analysis can’t
distinguish the difference between vitamin B6 responsive and non-responsive individuals.

Management of Homocystinuria

Treatment of Manifestations

The principle of treatment of manifestations is to correct the biochemical abnormalities,

such as the elevation of Homocysteine concentration in the blood, to prevent further complications
of homocystinuria.

These treatments include the vitamin B6 therapy, methionine-restricted diet, betaine

therapy, and folate and vitamin B12 supplementation.

Vitamin B6 (Pyridoxine) Therapy

 Vitamin B6 (Pyridoxine) therapy is used to individuals, experiencing homocystinuria type
1: vitamin B6 responsive. The amount of dosage is determined by measurement of total
Homocysteine and amino acid levels, which is approximately 200 mg/day or less.

Methionine-Restricted Diet

The methionine-restricted dietary plan is given to individuals with the homocystinuria type
1: vitamin B6 non-responsive. This diet should be continued indefinitely. Though in some cases,
betaine therapy can be used as an alternative treatment, but it is preferable to remain on the
metabolic diet.

The vitamin B6 responsive individuals are also required to take this dietary plan for
metabolic control.

The diet for this phenotype variant is very complex and hard that some individuals may
experience protein malnutrition. To prevent this protein malnutrition, a methionine-free amino
acid formula is provided. Breast feeding may also be continued in combination with the acid
formula for infants.

Folate and Vitamin B12 Supplementation

Both folate and vitamin B12 are utilized in the conversion of methionine to homocysteine
via methionine synthase, and thus, it helps in reducing the total amount of homocysteine in the
bloodstream.

This supplementation is applicable to all types of homocystinuria.

Betaine Treatment

As stated earlier, betaine treatment can be used as alternative treatment in individuals with
poor compliance with the dietary treatment. This treatment also reduces the homocysteine
concentrations to prevent severe complications like thromboembolism. However, methionine
concentrations also increase. Therefore, it is not advisable to take this supplement for those who
are experiencing multiple types of homocystinuria.
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