< Cc @ boardsbeyond.com Ww fh ee Quiz NIH researchers are studying leptin gene expression in diabetic patients. Their data show that diabetic patients have lower levels of leptin compared to age- matched nondiabetic controls. Which of the following changes would explain the decrease in leptin gene expression in the diabetic patient group? ~ A) Decreased histone deacetylase activity 8% > B) Increased histone acetyltransferase activity 5% © C) Decreased DNA methyltransferase activity 59% © D) Increased DNA methyltransferase activity 812% . Epigenetics Histone Acetylation Transcription PG DNA Methylation3:15 AM Sun 21 Jul = © 46% @_)+ @ boardsbeyond.com Me gk” DNA Methylation Answer D (correct answer): Epigenetics is the study of changes in gene expression that do not involve changes in the underlying gene itself. A number of biochemical changes to genetic material lead to increased or decreased gene expression. Two people may have identical genes but the expression may be different based on epigenetic modifications. For the Step 1 exam, some principles of epigenetics worth knowing are summarized in the slide above. Methylation of DNA leads to decreased gene expression. The enzyme that carries out DNA methylation is DNA methyltransferase. Acetylation of histones leads to increased gene expression. The enzyme that carries out histone acetylation is DNA acetyltransferase. The enzyme histone deacetyltransferase removes acetyl groups from histones leading to decreased gene expression. The following mnemonic may be helpful: "Methylation Mutes the genes, Acetylation Activates the genes. Answer C (incorrect answer): An increase in DNA methyltransferase activity results in methylation of “CG islands” within DNA. These DNA segments contain large amounts of the nucleotide base cytosine which can be methylated. When this occurs, DNA transcription is suppressed leading to less gene expression. Methylation has been described as a potential mechanism for decreased leptin levels in diabetics (See reference). A decrease in DNA methyltransferase activity would have the opposite effect on transcription and gene expression. Answers A and B (incorrect answers): Histone deacetylase removes acetyl groups from chromatin which decreases transcription and gene expression. A decrease in histone deacetylase activity would increase transcription and expression of leptin. Histone acetyltransferase adds acetyl groups to chromatin. This unwinds chromatin leading to increased gene expression. Reference: https://www.nature.com/articles/srepO05282 SECTION: Biochemistry » Molecular Biochemistry VIDEO: DNA StructureQuiz A.10-month-old male infant presents to your office with his mother. She reports the baby has been breathing faster than usual for the past day. Prior to this, her son had “a runny nose” for ‘several days. On physical exam, there is expiratory wheezing, intercostal retractions, and nasal flaring. Vitals include temperature 100.5F, blood pressure 110/70 mmHg, heart rate 140/min, and respiratory rate 35/min. A diagnosis of respiratory syncytial virus is made and anti-viral therapy is started. Enzymatic conversion of which of the following is the most likely target of the anti-viral therapy? © A)Phosphoribosyl pyrophosphate to inosine monophosphate 15.3% OB) Inosine monophosphate to guanosine monophosphate 64.6% C) Guanosine monophosphate to deoxyguanosine monophosphate 6.6 % D) Adenosine diphosphate to deoxyadenosine diphosphate 43% E) Ribose-5-phosphate to phorphoribosy! pyrophosphate 9.3% Ribavirin © 8 9 ar or IMP dehydrogenase ip flo on oy on ——-- - & —> pna Inosine monophosphate GHOH Guanosine-MP Respiratory Syncytial Virus (RSV) is a common cause of respiratory tract infections and3:17 AM Sun 21 Jul 2 © 46% @_)+ @ boardsbeyond.com O D) Adenosine diphosphate to deoxyadenosine diphosphate 4.3% OE) Ribose-5-phosphate to phorphoribosyl pyrophosphate 9.3% ETE Ribavirin 0 N 0 oy | Q i oO N™ *N N HO-P-O—5 6 0 U \ O~NHp OH IMP dehydrogenase HO-P—-o n~ _N we ————_> &: ib —> DNA Inosine monophosphate li (IMP) Guanosine-MP Respiratory Syncytial Virus (RSV) is acommon cause of respiratory tract infections and bronchiolitis in children less than 2 years of age. Bronchiolitis presents with wheezing and signs of increased work of breathing such as intercostal retractions and nasal flaring. Treatment for RSV bronchiolitis in infants is with ribavirin, an inhibitor of IMP dehydrogenase. This enzyme converts inosine monophosphate (IMP) to guanosine monophosphate (GMP) (answer B). Glutamine-PRPP amidotransferase converts PRPP to IMP (answer A) and is not affected by ribavirin. This enzyme is inhibited by autoregulatory negative feedback via IMP, AMP, and GMP. Conversion of GDP to dGDP (answer C) and ADP to dADP (answer D) is catalyzed by ribonucleotide reductase. This enzyme is inhibited by the drug hydroxyurea, which can be used in patients with myeloproliferative disorders, sickle cell disease and melanoma. Ribose-phosphate diphosphokinase converts ribose-5-phosphate to PRPP (answer E) at the start of purine synthesis. This enzyme also goes by the name of phosphoribosyl pyrophosphate synthetase or PRPP synthase. SECTION: Biochemistry » Molecular Biochemistry VIDEO: Purine Metabolism Question 1 of 63:18 AM Sun 21 Jul = © 46% @_)+ @ boardsbeyond.com Quiz A 2-year-old male infant is brought in by his mother because “he has been biting his fingers off.” His mother reports that this behavior has worsened over the past several months. She also states her child is often irritable and difficult to control. A 24-hour urine sample shows elevated uric acid. Measurement of which of the following enzymes would be most appropriate in the work-up of this patient? © A)IMP dehydrogenase 2.8% O B)UMP synthase 17% © C) Ornithine transcarbamylase 21% O D)Hypoxanthine-guanine phosphoribosyltransferase 924% © E) Adenine phosphoribosyltransferase 11% Lesch-Nyhan syndrome is an X-linked recessive enzyme deficiency of hypoxanthine-guanine phosphoribosyltransferase (HGPRT) characterized by hyperuricemia, self-mutilation/aggression, dystonia, and mental retardation. HGPRT (answer D) is an enzyme in the purine salvage pathway necessary for conversion of hypoxanthine and PRPP into IMP, as well as conversion of guanine and PRPP into GMP. Decreased enzyme activity leads to hyperuricemia. The etiology of the motor and behavioral aspects of Lesch-Nyhan is poorly understood but these features distinguish the disorder from other purely biochemical disorders of uric acid metabolism. HGPRT enzyme activity less than 1.5% of normal is diagnostic for Lesch-Nyhan syndrome. IMP dehydrogenase (answer A) converts IMP into GMP and is inhibited by the drug ribavirin, which is used in the treatment of RSV bronchiolitis. UMP synthase (answer B) deficiency results in orotic aciduria characterized by elevated orotic acid in the urine and megaloblastic anemia.3:18AM Sun 21 Jul Fe 46%80+ @ boardsbeyond.com Lesch-Nyhan syndrome is an X-linked recessive enzyme deficiency of hypoxanthine-guanine phosphoribosyltransferase (HGPRT) characterized by hyperuricemia, self-mutilation/aggression, dystonia, and mental retardation. HGPRT (answer D) is an enzyme in the purine salvage pathway necessary for conversion of hypoxanthine and PRPP into IMP, as well as conversion of guanine and PRPP into GMP. Decreased enzyme activity leads to hyperuricemia. The etiology of the motor and behavioral aspects of Lesch-Nyhan is poorly understood but these features distinguish the disorder from other purely biochemical disorders of uric acid metabolism. HGPRT enzyme activity less than 1.5% of normal is diagnostic for Lesch-Nyhan syndrome. IMP dehydrogenase (answer A) converts IMP into GMP and is inhibited by the drug ribavirin, which is used in the treatment of RSV bronchiolitis. UMP synthase (answer B) deficiency results in orotic aciduria characterized by elevated orotic acid in the urine and megaloblastic anemia. Ornithine transcarbamylase (OTC, answer C) deficiency is characterized by elevated orotic acid in the urine and hyperammonemia. Adenine phosphoribosyltransferase (answer E) converts adenine to AMP in the purine salvage pathway. Deficiency may cause elevated uric acid levels, but is not as associated with self- mutilation as seen in Lesch-Nyhan syndrome (HGPRT deficiency). SECTION: Biochemistry » Molecular Biochemistry VIDEO: Purine Metabolism Question 2 of 6 «GoBack Next» End Quiz3:19 AM Sun 21 Jul = © 46% @ _)+ @ boardsbeyond.com Bevel Mylan CyrMarvinie Oa sna TeV oo ve VIIZy TiS US Teenie y VT Ty PVACTIUTT me” & UCT rr phosphoribosyltransferase (HGPRT) characterized by hyperuricemia, self-mutilation/aggression, dystonia, and mental retardation. HGPRT is an enzyme in the purine salvage pathway. When purine salvage is defective, de novo purine synthesis increases to compensate. Shown in the slide above is the first step of de novo purine synthesis—the conversion of ribose-5- phosphate to PRPP (answer D) catalyzed by PRPP synthetase. This reaction will be upregulated in Lesch-Nyhan syndrome. Since cells cannot salvage purines, they must make more via de novo synthesis. The conversion of hypoxanthine to inosine monophosphate by hypoxanthine-guanine phosphoribosyltransferase (HGRT) (answer A) is a reaction of the purine salvage pathway. This pathway is defective in Lesch-Nyhan syndrome. The conversion of glutamine and carbon dioxide to carbamoyl phosphate (answer B) is catalyzed by carbamoyl phosphate synthetase II, a cytosolic enzyme which catalyzes the rate-limiting step of pyrimidine (not purine) synthesis. The conversion of adenine to adenosine monophosphate by adenine phosphoribosyltransferase (APRT) (answer C) is a reaction of the purine salvage pathway. This pathway is not part of de novo purine synthesis. Conversion of carbamoyl phosphate to orotic acid (answer E) is a component of pyrimidine (not purine) synthesis. SECTION: Biochemistry » Molecular Biochemistry VIDEO: Purine Metabolism Question 3 of 6 «GoBack Next» End Quiz3:21AM Sun 21 Jul = © 47% @_)4 @ boardsbeyond.com Quiz A 50-year-old male with a history of dyslipidemia, hypertension, and coronary artery disease presents with pain in his right great toe. The pain awakened him in the middle of the night. On exam, his right big toe is erythematous and swollen. Palpation elicits pain. Remainder of the physical exam is unremarkable. Review of systems is negative for fevers, night sweats, palpitations, or pain in other joints. A prophylactic medication with which of the following mechanisms of action would have best prevented this condition? © A) Irreversible inhibition of COX-1 and COX-2 1.6 % © B) Selective inhibition of COX-2 1% © C) Inhibition of xanthine oxidase 95.3% © D) Inhibition of microtubule polymerization 1.9% OE) Inhibition of phospholipase A2 0.3% Gout is a condition of recurrent attacks of acute inflammation in a large joint as a result of monosodium urate crystal deposition. Uric acid crystals activate neutrophils resulting in release of cytokines and other inflammatory mediators that result in pain, swelling, and erythema. The treatment of acute gout attacks involves anti-inflammatory drugs used on a short-term basis until symptoms resolve. For patients with recurrent attacks, prophylactic (preventative) drugs are used to reduce the risk of gout flares. Therapies to prevent gout are directed at lowering uric acid levels either by decreasing production or increasing excretion. Allopurinol, a xanthine oxidase inhibitor (answer C), is a first-line agent for prevention of gout attacks. The enzyme xanthine oxidase catalyzes conversion of hypoxanthine into xanthine, and conversion of xanthine into uric acid. Xanthine oxidase inhibitors reduce uric acid production and decrease the risk of recurrent gout attacks.monosodium urate crystal deposition. Uric acid crystals activate neutrophils resulting in release of cytokines and other inflammatory mediators that result in pain, swelling, and erythema. The treatment of acute gout attacks involves anti-inflammatory drugs used on a short-term basis until symptoms resolve. For patients with recurrent attacks, prophylactic (preventative) drugs are used to reduce the risk of gout flares. Therapies to prevent gout are directed at lowering uric acid levels either by decreasing production or increasing excretion. Allopurinol, a xanthine oxidase inhibitor (answer C), is a first-line agent for prevention of gout attacks. The enzyme xanthine oxidase catalyzes conversion of hypoxanthine into xanthine, and conversion of xanthine into uric acid. Xanthine oxidase inhibitors reduce uric acid production and decrease the risk of recurrent gout attacks. Non-steroidal anti-inflammatory drugs (NSAIDs) irreversibly inhibit COX-1 and COX-2 (answer A). These drugs can be used to treat acute gout attacks but are not effective as prophylaxis. In fact, low-dose aspirin taken on achronic basis can decrease uric acid excretion and thus increase the risk for gout attacks. Celecoxib selectively inhibits COX-2 (answer B) and is indicated in osteoarthritis and rheumatoid arthritis, but not for long-term gout therapy. Colchicine inhibits microtubule polymerization (answer D), and is used to treat acute gout attacks. Inhibition of microtubules inhibits cell trafficking that is necessary for a strong inflammatory response. Colchicine does not play a significant role in chronic therapy in decreasing uric acid levels or preventing future gout attacks. Glucocorticoids inhibit phospholipase A2 (answer E), resulting in decreased inflammation in the setting of acute gout attacks. Glucocorticoids have no role in decreasing uric acid levels for prevention of gout attacks. SECTION: Biochemistry » Molecular Biochemistry VIDEO: Purine Metabolism3:22 AM Sun 21 Jul = © 47% @_)4 @ boardsbeyond.com Quiz A 50-year-old female with a history of Crohn’s disease and gout presents for evaluation of fatigue. She complains of feeling more tired than usual with little energy for work or social activities. Her medications include azathioprine, natalizumab, prednisone, ciprofloxacin, and adalimumab. She also began taking allopurinol after having a gout attack six months ago. Lab testing reveals the following: Hemoglobin 8 g/dL (normal 12.0 to 15.5) Hematocrit 24% (normal 36 to 48) Mean corpuscular volume (MCV) 90 fL (normal 80 to 96) Leukocytes 4,800/mL (normal 4,500 to 11,000) Platelets 100,000/mL (normal 150,000 to 450,000) Plasma Folate 5.0 nmol/L (normal 4.5 to 45.3) Plasma B12 400 pg/mL (normal 200 to 500) Drug interaction between azathioprine and which of the following medications is the most likely cause of this patient’s CBC and symptoms? O A) Natalizumab 0.8% OB) Adalimumab 0.9% © C) Allopurinol 945% O D) Ciprofloxacin 2%3:22 AM Sun 21 Jul = © 47% @_)+ @ boardsbeyond.com © B) Adalimumab 0.9% © C) Allopurinol 94.5% OQ D) Ciprofloxacin 2% © E) Prednisone 18% Purine Salvage Drugs & Diseases * Azathioprine and 6-MP * Metabolized by xanthine oxidase * Caution with allopurinol » May boost effects - May increase toxicity S H = Xanthine H N Oxidase N NH N ——}> ot | A « | J N N~ *o N N HoH H Thiouric acid ial (inactive) This woman has pancytopenia: decreased red blood cells, white blood cells, and platelets. Given the recent addition of allopurinol, the most likely cause of pancytopenia Is an interaction between azathioprine and allopurinol (answer C). Azathioprine is pro-drug converted to the immunosupressant, 6-mercaptopurine (6-MP). Allopurinol inhibits xanthine oxidase resulting in decreased degradation of 6-MP. This leads to greater 6-MP effects and may cause pancytopenia. As above, azathioprine is a prodrug of 6-mercaptopurine (6-MP) which inhibits PRPP amidotransferase, an enzyme in the purine synthesis pathway. Inhibition of purine synthesis results in impaired DNA synthesis and subsequent cell death. At modest levels, this makes azathioprine useful in inflammatory and autoimmune conditions, including rheumatoid arthritis, Crohn’s disease, and glomerulonephritis. As shown in the slide above, azathioprine is converted to 6-MP and 6-MP is degraded by xanthine oxidase to an inactive metabolite, thiouric acid. With xanthine oxidase inhibition by allopurinol, 6-3:22 AM Sun 21 Jul = © A7%@_)4 @ boardsbeyond.com a an a nr the recent addition of allopurinol, the most likely cause of pancytopenia is an interaction between azathioprine and allopurinol (answer C). Azathioprine is pro-drug converted to the immunosupressant, 6-mercaptopurine (6-MP). Allopurinol inhibits xanthine oxidase resulting in decreased degradation of 6-MP. This leads to greater 6-MP effects and may cause pancytopenia. As above, azathioprine is a prodrug of 6-mercaptopurine (6-MP) which inhibits PRPP amidotransferase, an enzyme in the purine synthesis pathway. Inhibition of purine synthesis results in impaired DNA synthesis and subsequent cell death. At modest levels, this makes azathioprine useful in inflammatory and autoimmune conditions, including rheumatoid arthritis, Crohn’s disease, and glomerulonephritis. As shown in the slide above, azathioprine is converted to 6-MP and 6-MP is degraded by xanthine oxidase to an inactive metabolite, thiouric acid. With xanthine oxidase inhibition by allopurinol, 6- MP can accumulate to toxic levels leading to side effects. These include nausea, diarrhea, and pancytopenia. SECTION: Biochemistry » Molecular Biochemistry VIDEO: Purine Metabolism Question 5 of 6 «GoBack Next» End Quiz PTY Roarde2Revond3:23 AM Sun 21 Jul = © 47% @_)4 @ boardsbeyond.com Quiz Researchers discover a fungal compound that inhibits cellular metabolism via an unknown mechanism. The compound is isolated and administered to cells in culture. Shown below are the levels of several intracellular substances from cells grown in the presence of the new fungal compound compared to normal cells (i.e., cells grown without exposure to the fungal compound). Hime Ce Il % of substance Substance Ame iiel met ey) Glucose-6 Phosphate 102% 152% Based on these data, the fungal compound inhibits synthesis of which of the following? A) Proteins B ) Glycogen C) Purines D ) Pyrimidines E) Fatty acids O OO O08 OO OO O F ) Pyruvate Question 6 of 6 « Go Back le ae esCee Sait) = ®© A7%@ 4 lik] Boards and Beyond < G @ boardsbeyond.com § wv (4 ‘oe compound compared to normal cells (i.e., cells grown without exposure to the fungal compound). Intracellular % of substance SDH aty re bit os (vs. normal cells) Glucose-6 Phosphate 102% Orotic Acid 152% Based on these data, the fungal compound inhibits synthesis of which of the following? O A) Proteins 0.7% © B) Glycogen 0.4% © C)Purines 84.6 % © D)Pyrimidines 13.4% O E) Fatty acids 0.4% O F) Pyruvate 0.5% The data indicate reduced levels of inosine monophosphate (IMP) among cells grown in the presence of the fungal compound. IMP is an intermediate in the synthesis of purines (answer C), which include nucleotides such as adenosine and guanosine that contain bases with two rings (in contrast to pyrimidines bases which have a single ring). The data imply that the fungal compound's mechanism of action is inhibition of purine synthesis. Glucose-6 phosphate is an intermediate in glycolysis and glycogen (answer B) synthesis. The levels are not affected by the fungal compound according to the data. a Fh , acai a FF 2 oo ee Se ‘ pre ad Le oe. ee of i | t,o en | ' '. soi0-29 AVE OU Zi vu ‘oe SS 4/7 ae) 7 ? 9° @ boardsbeyond.com © E) Fatty acids 0.4% O F) Pyruvate 0.5 % The data indicate reduced levels of inosine monophosphate (IMP) among cells grown in the presence of the fungal compound. IMP is an intermediate in the synthesis of purines (answer C), which include nucleotides such as adenosine and guanosine that contain bases with two rings (in contrast to pyrimidines bases which have a single ring). The data imply that the fungal compound's mechanism of action is inhibition of purine synthesis. Glucose-6 phosphate is an intermediate in glycolysis and glycogen (answer B) synthesis. The levels are not affected by the fungal compound according to the data. Malonyl-CoA is an intermediate in the synthesis of fatty acids (answer E). Its levels are also not affected by the fungal compound according to the data. Proline is an amino acid used to synthesize proteins (answer A), especially collagen. The data indicate that proline levels are not diminished by the fungal compound. Pyrimidines (answer D) are nucleic acids such cytidine, thymidine, and uridine. These compounds have bases with a single ring. IMP is not an intermediate in pyrimidine synthesis, and reduced IMP will not lead to reduced pyrimidine levels. Note that the data indicate a rise in the level of orotic acid, an intermediate in pyrimidine synthesis. This is a distractor that implies pyrimidine synthesis is increased in the presence of the fungal compound. Pyruvate (answer F) is the end product of glycolysis. Nothing in the data indicates inhibition of glycolysis. SECTION: Biochemistry » Molecular Biochemistry VIDEO: Purine Metabolism Question 6 of 6 « Go Back3:24 AM Sun 21 Jul = © 48% @)+ @ boardsbeyond.com Quiz A 1-year-old male infant presents with a history of recurrent upper respiratory infections, failure to thrive, and anemia. Vital signs are temperature 98.8F, blood pressure 110/70 mmHg, heart rate 135/min, and respiratory rate 30/min. For the past month, he has been taking pyridoxine, folate, and cobalamin supplements without improvement. Further work-up reveals excess urinary orotic acid. A blood smear is shown below. Deficiency of which of the following enzymes is most likely responsible for this patient’s underlying condition? i™\ aa. Wikipedia/Public Domain O A) Ornithine transcarbamylase 25.6 % O B)Hypoxanthine-guanine phosphoribosyltransferase 2.8 % © C) Uridine monophosphate synthase 70.8 % O D) Pyruvate kinase 0.3% © E) Pyruvate dehydrogenase 0.4%3:24 AM Sun 21 Jul = © 48% @@ _)+ @ boardsbeyond.com Pyrimidine Synthesis » Step 3: Make UMP 0 O O NH NH aun r C HO | hs Synthase nor © ¥ Ay Nn “Oo — OH O H Orotic Acid OH OH o eee Uridine-MP il O : ; a 9 O-P—O-P-O° oHoH Gd 5-Phosphoribosyl-1-pyrophosphate (PRPP) UMP synthase deficiency (answer C), also called orotic aciduria, presents in infancy with failure to thrive, recurrent infections, and megaloblastic anemia. In megaloblastic anemia, hypersegmented neutrophils can be observed on the blood smear as shown above. More common causes of megaloblastic anemia are vitamin deficiencies including folate and B12. In orotic aciduria, vitamin supplementation with B9 or B12 is ineffective due to decreased activity of UMP synthase. Treatment is with uridine supplementation. Uridine is converted to uridine monophosphate (UMP) to bypass the defective UMP synthase enzyme. Infants with UMP synthase deficiency have normal ammonia levels. In a related biochemical disorder, ornithine transcarbamylase (OTC) deficiency (answer A), orotic aciduria also occurs. This disorder involves the urea cycle and hyperammonemia is present. In addition, blood smear is unremarkable (no megaloblastic anemia or hypersegmented neutrophils) in ornithine transcarbamylase deficiency. Hypoxanthine-guanine phosphoribosyltransferase (HGPRT) deficiency causes Lesch-Nyhan syndrome characterized by hyperuricemia, self-mutilation/aggression, dystonia, and mental retardation (answer B). Pyruvate kinase deficiency (answer D) presents as neonatal hemolytic anemia with jaundice, hanatncnlannmacaly and a nacative Camambe tact[@l Boards and Beyond < CG @ boardsbeyond.com yy tho neutrophils can be observed on the blood smear as shown above. More common causes of megaloblastic anemia are vitamin deficiencies including folate and B12. In orotic aciduria, vitamin supplementation with B9 or B12 is ineffective due to decreased activity of UMP synthase. Treatment is with uridine supplementation. Uridine is converted to uridine monophosphate (UMP) to bypass the defective UMP synthase enzyme. Infants with UMP synthase deficiency have normal ammonia levels. In a related biochemical disorder, ornithine transcarbamylase (OTC) deficiency (answer A), orotic aciduria also occurs. This disorder involves the urea cycle and hyperammonemiais present. In addition, blood smear is unremarkable (no megaloblastic anemia or hypersegmented neutrophils) in ornithine transcarbamylase deficiency. Hypoxanthine-guanine phosphoribosyltransferase (HGPRT) deficiency causes Lesch-Nyhan syndrome characterized by hyperuricemia, self-mutilation/aggression, dystonia, and mental retardation (answer B). Pyruvate kinase deficiency (answer D) presents as neonatal hemolytic anemia with jaundice, hepatosplenomegaly, and a negative Coombs test. Pyruvate dehydrogenase deficiency (answer E) is an X-linked disorder characterized by lactic acidosis, microcephaly, neurologic deficits, and hypotonia. SECTION: Biochemistry » Molecular Biochemistry VIDEO: Pyrimidine Metabolism Question 1 of 5 Next » End Quiz3:25 AM Sun 21 Jul = © 48% @_)+ @ boardsbeyond.com Quiz A 1-year-old male infant presents with a history of recurrent upper respiratory infections, failure to thrive, and anemia. Vital signs are temperature 98.7F, blood pressure 110/70 mmHg, heart rate 135/min, and respiratory rate 30/min. For the past month, he has been taking pyridoxine, folate, and cobalamin supplements without improvement. Further work-up reveals excess urinary orotic acid. A blood smear is shown below. Which of the following sets of lab values are most likely in this patient relative to a healthy infant? (RBC = red blood cells; MCV = mean corpuscular volume) +» * Wikipedia/Public Domain RBC Count MCV Reticulocyte Count Ammonia Normal re | Decreased | Increased | Increased | Normal c rp | Decreased | Increased | Decreased | Normal Pe [Normal [Normal [Normal | High3:25 AM Sun 21 Jul > © 48% @_)4 @ boardsbeyond.com RBC Count COAT Reticulocyte Count Ammonia Te | Decreased | Increased | Increased | Normal c TD | Decreased | Increased | Decreased | Normal Pe [Normal [Normal [Normal [High OA 2.8% OB 36.3% OC 13.9 % ©D 46 % OE 1% UMP synthase deficiency (also called orotic aciduria) presents in infancy with failure to thrive, recurrent infections, and megaloblastic anemia that is refractory to folate (vitamin BY) and B12 therapy. In orotic aciduria, vitamin supplementation is ineffective due to decreased activity of UMP synthase. Treatment is with uridine supplementation. Uridine is converted to uridine monophosphate (UMP) to bypass the defective UMP synthase enzyme. The image shows a hypersegmented neutrophil. These are seen with impaired DNA synthesis. Causes of hypersegmented neutrophils include any cause of megaloblastic anemia such as B12 deficiency, folate deficiency, and pyrimidine synthesis defects (e.g., orotic aciduria). Chemotherapeutic agents that impair DNA synthesis may also cause megaloblastic anemia. In megaloblastic anemia, red blood cell (RBC) production is decreased resulting in a decreased RBC count. Mean corpuscular volume (MCV) is increased in all megaloblastic anemias. Reticulocyte count should rise in the setting of anemia but does not in orotic aciduria due to defective nucleotide synthesis. Ammonia levels are normal in UMP synthase deficiency (answer D). Ammonia levels rise in ornithine transcarbamvlase (OTC) deficiency. a urea cvcle disorder that3:25 AM Sun 21 Jul Fe 48%— @ boardsbeyond.com UMP synthase deficiency (also called orotic aciduria) presents in infancy with failure to thrive, recurrent infections, and megaloblastic anemia that is refractory to folate (vitamin B9) and B12 therapy. In orotic aciduria, vitamin supplementation is ineffective due to decreased activity of UMP synthase. Treatment is with uridine supplementation. Uridine is converted to uridine monophosphate (UMP) to bypass the defective UMP synthase enzyme. The image shows a hypersegmented neutrophil. These are seen with impaired DNA synthesis. Causes of hypersegmented neutrophils include any cause of megaloblastic anemia such as B12 deficiency, folate deficiency, and pyrimidine synthesis defects (e.g., orotic aciduria). Chemotherapeutic agents that impair DNA synthesis may also cause megaloblastic anemia. In megaloblastic anemia, red blood cell (RBC) production is decreased resulting in a decreased RBC count. Mean corpuscular volume (MCV) is increased in all megaloblastic anemias. Reticulocyte count should rise in the setting of anemia but does not in orotic aciduria due to defective nucleotide synthesis. Ammonia levels are normal in UMP synthase deficiency (answer D). Ammonia levels rise in ornithine transcarbamylase (OTC) deficiency, a urea cycle disorder that also causes increased orotic acid levels. SECTION: Biochemistry » Molecular Biochemistry VIDEO: Pyrimidine Metabolism Question 2 of 5 «GoBack Next» End Quiz3:26 AM Sun 21 Jul = © 49% @ )+ @ boardsbeyond.com Videos Books Quizzes Index Samples _ Pricing Quiz A 44-year-old woman comes to your office for her annual check-up. Vital signs are temperature 98.7F, blood pressure 130/76 mmHg, heart rate 60/min, and respiratory rate 20/min. On physical exam, she has decreased vibratory sensation in both of her lower extremities. Her labs and blood smear are as follows: Hemoglobin 112g/dL (normal 12.0 to 15.5) Hematocrit 33% (normal 36 to 48) Leukocytes 9,500/mm3 (normal 4,500 to 11,000) Platelets 250,000/mm3 (normal 150,000 to 450,000) Plasma Folate 7.8nmol/L (normal 4.5 to 45.3) Plasma B12 100pg¢/mL (normal 200 to 500) Lai. Wikipedia/Public Domain Further work-up would most likely reveal which of the following sets of values for this patient ramnarad ta narmal far rad hlnand rall maaan rarniiceiular walhiuma (AACVA and nlacma lavale nf3:26 AM Sun 21 Jul = © 49% @)4 @ boardsbeyond.com ( ® Further work-up would most likely reveal which of the following sets of values for this patient Wikipedia/Public Domain compared to normal for red blood cell mean corpuscular volume (MCV) and plasma levels of homocysteine and methylmalonic acid? Homocysteine Methylmalonic Acid MCV Te | tnereased | Increased | ___Increased [> | increased | Normal | _Normal Te [increased | Increased [Normal O 1.2% O 88.6 % Oc 5.4% ° 11% o£ 3.7% Homocysteine and MMACPL) ea Lal ein la] Boards and Beyond Homocysteine and MMA Folate —- N5-Methyl THF THF Bi2 Homocysteine Methionine Methylmalonic Acid (MMA) ' B12 Methylmalonyl CoA —W SS Surccinyl COA This woman has a vitamin B12 deficiency which causes megaloblastic anemia and neurologic symptoms. In megaloblastic anemias, red blood cell counts are decreased and mean corpuscular volume (i.e., red blood cell size) is increased. In addition to megaloblastic anemia, vitamin B12 deficiency causes loss of vibratory sensation in the lower extremities. Liver stores of vitamin B12 can last for three to four years. For this reason, sustained decreased vitamin intake or absorption is required to develop symptomatic deficiency. This may occur with strict veganism, Diphyllobothrium latum (a helminth) infection, resection of the terminal ileum or pernicious anemia (autoimmune gastritis). Folate (vitamin BY) deficiency may also cause megaloblastic anemia. Deficiency of this vitamin is more common as total body stores are lower than vitamin B12. In contrast to vitamin B12, folate deficiency does not cause neurologic symptoms. In addition, while folate and B12 deficiencies both cause increased homocysteine levels, only B12 deficiency causes an increase in methylmalonic acid (MMA). Both folate and B12 are necessary to convert homocysteine to methionine. Deficiency of either vitamin results in increased homocysteine levels. However, B12 is also necessary for thef@ boardsbeyond.com This woman has a vitamin B12 deficiency which causes megaloblastic anemia and neurologic symptoms. In megaloblastic anemias, red blood cell counts are decreased and mean corpuscular , red blood cell size) is increased. In addition to megaloblastic anemia, vitamin B12 deficiency causes loss of vibratory sensation in the lower extremities. volume Liver stores of vitamin B12 can last for three to four years. For this reason, sustained decreased vitamin intake or absorption is required to develop symptomatic deficiency. This may occur with strict veganism, Diphyllobothrium latum (a helminth) infection, resection of the terminal ileum or pernicious anemia (autoimmune gastritis). Folate (vitamin B9) deficiency may also cause megaloblastic anemia. Deficiency of this vitamin is more commonas total body stores are lower than vitamin B12. In contrast to vitamin B12, folate deficiency does not cause neurologic symptoms. In addition, while folate and B12 deficiencies both cause increased homocysteine levels, only B12 deficiency causes an increase in methylmalonic acid (MMA). Both folate and B12 are necessary to convert homocysteine to methionine. Deficiency of either vitamin results in increased homocysteine levels. However, B12 is also necessary for the conversion of methylmalonyl CoA (the CoA-linked form of MMA) to succinyl CoA via methylmalony! CoA mutase. Without B12 present as a cofactor in this reaction, MMA levels will increase. Increased MCV, increased homocysteine, and increased MMA (answer B) would be expected in this woman with vitamin B12 deficiency. In folate deficiency, increased MCV, increased homocysteine, and normal MMA levels would occur (answer E). SECTION: Biochemistry » Molecular Biochemistry VIDEO: Pyrimidine Metabolism Question 3 of 5 «GoBack Next» End Quiz3:27 AM Sun 21 Jul 2 © 49% @ _)+4 @ boardsbeyond.com Quiz A 65-year-old female presents to your office with a lesion on her right cheek. The lesionis a waxy, pearly nodule with rolled borders and central ulceration. The patient is prescribed 5- Fluorouracil to be applied topically to the right cheek. Which of the following changes in intracellular thymidine and uridine levels will occur in the treated skin region? Pileelestiiele Intracellular OWN cedni: Ube ttt: “p | Increased | Decreased “> | Decreased | Decreased Te | vecreased | tnervased OA 1.5 % Og 43% oO ¢ 13% OD 14.2% » £ 76.7% OF 1.5 % OG 0.6 %3:27 AM Sun 21 Jul 2 © 49% @ _)+ @ boardsbeyond.com Thymidine QO g . 0 Or ha) Lol SO Thymidylate HO-P-o N~ So \_/ Synthase ss Bs OH OH dUridine-MP Thymidine-MP N5, N10 Tetrahydrofolate DHF <—— Folate \ Dihydrofolate THF Reductase * Folate = 1 carbon carriers The patient in this vignette has basal cell carcinoma, which classically presents as a pearly nodule with rolled borders and central ulceration. Treatment for basal cell carcinoma can include 5- Fluorouracil (5-FU). This drug is a pyrimidine analog that is activated to 5-fluoro-deoxy-uridine monophosphate (5-FdUMP) which binds N5,N10-tetrahydrofolate and inhibits thymidylate synthase. Inhibition of thymidylate synthase by 5-FU decreases intracellular thymidine and increases intracellular uridine (answer E). This can be appreciated in the diagram above, which shows that without thymidylate synthase, (UMP will accumulate upstream of the inhibited enzyme. SECTION: Biochemistry » Molecular Biochemistry VIDEO: Pyrimidine Metabolism Question 4 of 5 «GoBack Next»Quiz 60-year-old man presents with burning pain in the hands and feet. Laboratory testing reveals a platelet count of 1,000,000/microL. He is started on therapy with hydroxyurea. Which of the following may develop as a result of this treatment? A) Microcytic anemia 12.3% B) Hemorrhagic cystitis 3.3% © C) Increased mean corpuscular volume (MCV) 78.3% D) Pulmonary fibrosis 2.2% E) Arterial thrombosis 3.9% The question describes a case of essential thrombocytosis (ET). ET is a myeloproliferative disorder of megakaryocyte proliferation leading to elevated platelet counts. One of the symptoms that may occur is erythromelalgia, or redness and burning pain of the hands and feet (this syndrome may also be seen in polycythemia vera). Low risk cases can be observed without treatment. High risk cases are treated with drug therapy to prevent complications such as thrombosis or bleeding. Hydroxyurea reduces the platelet count in ET. In clinical trials, it has been shown to reduce rates of thrombosis. Hydroxyurea inl pyrimidine synthesis via inhibition of the enzyme ribonucleotide reductase. When pyrimidine synthesis is inhibited, DNA production is limited. This leads to a megaloblastic anemia including a low red cell count and high mean corpuscular volume (answer C). In fact, a rise in the MCV can be used to establish that patients are taking hydroxyurea, and that the therapy is exerting a biologic effect. There are many causes of a megaloblastic anemia including a number of drugs that blunt pyrimidine (and, therefore, DNA) synthesis. These include hydroxyurea, methotrexate, and 5- fluorouracil.3:28 AM Sun 21 Jul 2 © 50% @_)4 @ boardsbeyond.com syndrome may also be seen in polycythemia vera). Low risk cases can be observed without treatment. High risk cases are treated with drug therapy to prevent complications such as thrombosis or bleeding. Hydroxyurea reduces the platelet count in ET. In clinical trials, it has been shown to reduce rates of thrombosis. Hydroxyurea inhibits pyrimidine synthesis via inhibition of the enzyme ribonucleotide reductase. When pyrimidine synthesis is inhibited, DNA production is limited. This leads to a megaloblastic anemia including a low red cell count and high mean corpuscular volume (answer C). In fact, a rise in the MCV can be used to establish that patients are taking hydroxyurea, and that the therapy is exerting a biologic effect. There are many causes of a megaloblastic anemia including a number of drugs that blunt pyrimidine (and, therefore, DNA) synthesis. These include hydroxyurea, methotrexate, and 5- fluorouracil. A microcytic anemia (choice A) may be seen in iron deficiency, thalassemia, and many other Causes. Hemorrhagic cystitis (choice B) can occur after therapy with cyclophosphamide. Pulmonary fibrosis (choice D) is a potential complication of bleomycin therapy. Hydroxyurea decreases the rate of thrombosis (answer E). SECTION: Biochemistry » Molecular Biochemistry VIDEO: Pyrimidine Metabolism Question 50f 5 « Go Back End Quiz