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https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. , and many manifest both regional lipomatous overgrowth and lipoatrophy. Persons with PS do not have the typical ovoid, encapsulated lipomas common in the elderly and so the term "lipoma" is technically incorrect, but in wide usage. Fatty infiltration of the myocardium, particularly the intraventicular septum, has been observed in a number of children and adults with PS with no functional consequences .Vascular malformations. Many individuals with PS have cutaneous capillary malformations and prominent venous patterning or varicosities; large and complex vascular malformations affect some individuals. Vascular malformations are commonly recognized in the first months of life and are generally stable over time . Lymphatic vascular malformations can arise in any tissue that normally includes such vessels. These can be progressive and are often present with areas of lipomatous overgrowth, which can complicate surgical approaches to lipomas.The most urgent and life-threatening complication of PS can be deep vein thrombosis (DVT) and pulmonary embolism (PE) . Individuals with
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. venous patterning or varicosities; large and complex vascular malformations affect some individuals. Vascular malformations are commonly recognized in the first months of life and are generally stable over time . Lymphatic vascular malformations can arise in any tissue that normally includes such vessels. These can be progressive and are often present with areas of lipomatous overgrowth, which can complicate surgical approaches to lipomas.The most urgent and life-threatening complication of PS can be deep vein thrombosis (DVT) and pulmonary embolism (PE) . Individuals with DVT can present with a palpable subcutaneous rope-like mass, swelling, erythema, pain, and distal venous congestion. Symptoms of PE include shortness of breath, chest pain, and cough which may include hemoptysis. The rarity of DVT and PE in the general pediatric population can result in a delay in diagnosis.Those with PS manifest skeletal and other overgrowth in areas where no vascular malformations are present (unlike some other overgrowth conditions).Importantly, arteriovenous malformation (AVM) is
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. PE) . Individuals with DVT can present with a palpable subcutaneous rope-like mass, swelling, erythema, pain, and distal venous congestion. Symptoms of PE include shortness of breath, chest pain, and cough which may include hemoptysis. The rarity of DVT and PE in the general pediatric population can result in a delay in diagnosis.Those with PS manifest skeletal and other overgrowth in areas where no vascular malformations are present (unlike some other overgrowth conditions).Importantly, arteriovenous malformation (AVM) is uncommon in PS.Tumors, most of which are benign. Tumors observed in multiple individuals include meningiomas, ovarian cystadenomas, and parotid monomorphic adenomas. A number of other tumors have been seen in individual patients with PS. It is presumed that PS causes a modest but significant increase in many types of tumors, in contrast to other syndromes that are associated with a very specific subset of tumors.Bullous pulmonary disease is uncommon but does affect some individuals with PS , most
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. malformation (AVM) is uncommon in PS.Tumors, most of which are benign. Tumors observed in multiple individuals include meningiomas, ovarian cystadenomas, and parotid monomorphic adenomas. A number of other tumors have been seen in individual patients with PS. It is presumed that PS causes a modest but significant increase in many types of tumors, in contrast to other syndromes that are associated with a very specific subset of tumors.Bullous pulmonary disease is uncommon but does affect some individuals with PS , most commonly in late childhood or adolescence. As with other disease manifestations, this can progress with startling rapidity. It commonly manifests by reduced exercise tolerance or as an incidental finding from chest imaging.Dysmorphic facial features typically evolve during childhood and are not obvious at birth. Reported facial features include dolichocephaly, long face, downslanting palpebral fissures, and/or minor ptosis, depressed nasal bridge, wide or anteverted nares,
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. individuals with PS , most commonly in late childhood or adolescence. As with other disease manifestations, this can progress with startling rapidity. It commonly manifests by reduced exercise tolerance or as an incidental finding from chest imaging.Dysmorphic facial features typically evolve during childhood and are not obvious at birth. Reported facial features include dolichocephaly, long face, downslanting palpebral fissures, and/or minor ptosis, depressed nasal bridge, wide or anteverted nares, and open mouth at rest.Psychosocial issues. In addition to functional compromise, the skeletal and connective tissue overgrowth of PS can result in disfigurement for some individuals, a significant concern for many families . This condition is progressive and the degree of severity varies widely among individuals, creating uncertainty for both clinicians and families. Coping with an ultra-rare and chronic condition like PS poses challenges for many individuals and families.Prognosis is based on the location and degree of the overgrowth present in the
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. everted nares, and open mouth at rest.Psychosocial issues. In addition to functional compromise, the skeletal and connective tissue overgrowth of PS can result in disfigurement for some individuals, a significant concern for many families . This condition is progressive and the degree of severity varies widely among individuals, creating uncertainty for both clinicians and families. Coping with an ultra-rare and chronic condition like PS poses challenges for many individuals and families.Prognosis is based on the location and degree of the overgrowth present in the individual and the presence or absence of significant complications such as bullous pulmonary disease, hemimegencephaly, and pulmonary embolism. The disorder is highly variable. While it is difficult to calculate life expectancy, it is clear that there are many more children with PS than adults. With appropriate management, mildly affected individuals have an excellent prognosis.Genotype-Phenotype CorrelationsPS is known to be caused by only a single, mosaic pathogenic variant (p.Glu17Lys) in AKT1. A
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. the overgrowth present in the individual and the presence or absence of significant complications such as bullous pulmonary disease, hemimegencephaly, and pulmonary embolism. The disorder is highly variable. While it is difficult to calculate life expectancy, it is clear that there are many more children with PS than adults. With appropriate management, mildly affected individuals have an excellent prognosis.Genotype-Phenotype CorrelationsPS is known to be caused by only a single, mosaic pathogenic variant (p.Glu17Lys) in AKT1. A detailed autopsy study of an individual showed that while there was an overall correlation of variant levels with the presence of gross or histologic manifestations of overgrowth (hypertrophy or hyperplasia), this correlation was not tight nor absolute. Some tissues with overgrowth had no detectable variant, while other apparently unaffected tissues did harbor the variant. Clinicians should be cautious when assuming that a tissue or organ is unaffected by this disease.PenetranceIncomplete penetrance cannot be assessed in a mosaic genetic disorder that is not inherited
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. in AKT1. A detailed autopsy study of an individual showed that while there was an overall correlation of variant levels with the presence of gross or histologic manifestations of overgrowth (hypertrophy or hyperplasia), this correlation was not tight nor absolute. Some tissues with overgrowth had no detectable variant, while other apparently unaffected tissues did harbor the variant. Clinicians should be cautious when assuming that a tissue or organ is unaffected by this disease.PenetranceIncomplete penetrance cannot be assessed in a mosaic genetic disorder that is not inherited.NomenclatureOther descriptors used include elephant man disease. This descriptor is derived from the fact that Mr. Joseph Carey Merrick, who held this unfortunate descriptor, is now thought to have had PS . The use of this descriptor for other than historical purposes is discouraged.PrevalencePS is very rare. The prevalence is difficult to measure, but approximately 100 individuals are known to the author . A very rough estimate is that PS affects 1:
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. disorder that is not inherited.NomenclatureOther descriptors used include elephant man disease. This descriptor is derived from the fact that Mr. Joseph Carey Merrick, who held this unfortunate descriptor, is now thought to have had PS . The use of this descriptor for other than historical purposes is discouraged.PrevalencePS is very rare. The prevalence is difficult to measure, but approximately 100 individuals are known to the author . A very rough estimate is that PS affects 1:1,000,000 – 1:10,000,000 persons.PS is pan ethnic.Differential DiagnosisSignificant diagnostic confusion regarding Proteus syndrome (PS) exists. Although the following disorders share some features with PS, both the natural history (i.e., almost always postnatal onset) and manifestations (e.g., disproportionate and progressive distorting skeletal overgrowth, CCTN) of PS are important distinctions that can aid in clinical diagnosis.PTEN hamartoma
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. that PS affects 1:1,000,000 – 1:10,000,000 persons.PS is pan ethnic.Differential DiagnosisSignificant diagnostic confusion regarding Proteus syndrome (PS) exists. Although the following disorders share some features with PS, both the natural history (i.e., almost always postnatal onset) and manifestations (e.g., disproportionate and progressive distorting skeletal overgrowth, CCTN) of PS are important distinctions that can aid in clinical diagnosis.PTEN hamartoma tumor syndrome (PHTS) is a heterogeneous disorder that manifests asymmetric overgrowth, macrocephaly, cutaneous vascular malformations, and tumor susceptibility. The full spectrum of this interesting and distinctive disorder is not known, but it can be readily distinguished from PS. A phenotypic subtype, described as type II segmental Cowden syndrome or SOLAMEN syndrome , is the consequence of a germline pathogenic variant in PTEN with a somatic, mosaic second PTEN variant that gives the phenotype its segmental attributes.PTHS includes
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. diagnosis.PTEN hamartoma tumor syndrome (PHTS) is a heterogeneous disorder that manifests asymmetric overgrowth, macrocephaly, cutaneous vascular malformations, and tumor susceptibility. The full spectrum of this interesting and distinctive disorder is not known, but it can be readily distinguished from PS. A phenotypic subtype, described as type II segmental Cowden syndrome or SOLAMEN syndrome , is the consequence of a germline pathogenic variant in PTEN with a somatic, mosaic second PTEN variant that gives the phenotype its segmental attributes.PTHS includes growth abnormalities with linear nevi and vascular malformations that are clinically and molecularly distinct from those of PS.PTHS is inherited in an autosomal dominant manner; PS is not inherited. Thus, the genetic implications in the two disorders are quite distinct, providing further argument for a clear distinction between individuals affected with PS and those with PTHS.CLOVE(S) syndrome (congenital lipomatous asymmetric overgrowth of the trunk, lymphatic, capillary, venous, and combined-type vascular malformations
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. attributes.PTHS includes growth abnormalities with linear nevi and vascular malformations that are clinically and molecularly distinct from those of PS.PTHS is inherited in an autosomal dominant manner; PS is not inherited. Thus, the genetic implications in the two disorders are quite distinct, providing further argument for a clear distinction between individuals affected with PS and those with PTHS.CLOVE(S) syndrome (congenital lipomatous asymmetric overgrowth of the trunk, lymphatic, capillary, venous, and combined-type vascular malformations, epidermal nevi, skeletal and spinal anomalies) is one of several now-distinct entities previously included in the heterogeneous designation of PS . It manifests prenatal asymmetric overgrowth that is primarily proportionate in nature. Affected persons commonly have splayed feet and toes. The vascular malformations are most commonly combined lymphatico-venous anomalies with cutaneous blebbing and weeping. The lipomatous nature of the overgrowth is characterized by overgrowth of fat within normal fatty fascial planes and linear
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. combined-type vascular malformations, epidermal nevi, skeletal and spinal anomalies) is one of several now-distinct entities previously included in the heterogeneous designation of PS . It manifests prenatal asymmetric overgrowth that is primarily proportionate in nature. Affected persons commonly have splayed feet and toes. The vascular malformations are most commonly combined lymphatico-venous anomalies with cutaneous blebbing and weeping. The lipomatous nature of the overgrowth is characterized by overgrowth of fat within normal fatty fascial planes and linear verrucous epidermal nevi. Some persons can have CNS abnormalities. See PIK3CA-Related Segmental Overgrowth.Hemihyperplasia, either as an isolated finding or associated with one of a variety of other manifestations (for review, see Cohen et al ), should be considered. One of the more specific types of hemihyperplasia is the hemihyperplasia with multiple lipomatosis syndrome . This congenital, primarily non-progressive form of hemihyperplasia is sometimes confused with PS.
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. fascial planes and linear verrucous epidermal nevi. Some persons can have CNS abnormalities. See PIK3CA-Related Segmental Overgrowth.Hemihyperplasia, either as an isolated finding or associated with one of a variety of other manifestations (for review, see Cohen et al ), should be considered. One of the more specific types of hemihyperplasia is the hemihyperplasia with multiple lipomatosis syndrome . This congenital, primarily non-progressive form of hemihyperplasia is sometimes confused with PS.Klippel-Trenaunay syndrome is a disorder that manifests both overgrowth and vascular malformations. However, in this disorder the overgrowth is generally ipsilateral and overlapping with the vascular malformations, the typical vascular malformation is the lateral venous anomaly, and the skeletal overgrowth is entirely lacking in the distortion and progressivity seen in persons with PS .ManagementEvaluations Following Initial DiagnosisTo establish the extent of disease in an individual diagnosed with Proteus syndrome (PS), the following evaluations are recommended if
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. sometimes confused with PS.Klippel-Trenaunay syndrome is a disorder that manifests both overgrowth and vascular malformations. However, in this disorder the overgrowth is generally ipsilateral and overlapping with the vascular malformations, the typical vascular malformation is the lateral venous anomaly, and the skeletal overgrowth is entirely lacking in the distortion and progressivity seen in persons with PS .ManagementEvaluations Following Initial DiagnosisTo establish the extent of disease in an individual diagnosed with Proteus syndrome (PS), the following evaluations are recommended if they have not already been completed :Detailed and comprehensive (general, spine, and hand) orthopedic evaluationSkeletal survey as a baseline study of the extent and severity of overgrowthCT examination, possibly with three-dimensional reconstruction for individuals with significant scoliosis. As the vertebral bodies are commonly progressively deformed, this study can be very helpful for surgical planning.Pulmonology consultation, pulmonary function testing, and high-resolution CT examination of the chest for individuals with signs or symptoms suggestive of bullous pulmonary disease
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. following evaluations are recommended if they have not already been completed :Detailed and comprehensive (general, spine, and hand) orthopedic evaluationSkeletal survey as a baseline study of the extent and severity of overgrowthCT examination, possibly with three-dimensional reconstruction for individuals with significant scoliosis. As the vertebral bodies are commonly progressively deformed, this study can be very helpful for surgical planning.Pulmonology consultation, pulmonary function testing, and high-resolution CT examination of the chest for individuals with signs or symptoms suggestive of bullous pulmonary diseaseNeurodevelopmental evaluation for those with developmental delaysConsultation with a clinical geneticist and/or genetic counselorRehabilitation medicine evaluation, including fabrication of custom footwear and orthotics to address functional consequences of overgrowthOther imaging techniques (e.g., CT, MRI, and ultrasound examinations) are highly useful and should be determined by manifestations on examination and by the medical history.Treatment of ManifestationsAs with any complex and multisystem disorder, individuals
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. suggestive of bullous pulmonary diseaseNeurodevelopmental evaluation for those with developmental delaysConsultation with a clinical geneticist and/or genetic counselorRehabilitation medicine evaluation, including fabrication of custom footwear and orthotics to address functional consequences of overgrowthOther imaging techniques (e.g., CT, MRI, and ultrasound examinations) are highly useful and should be determined by manifestations on examination and by the medical history.Treatment of ManifestationsAs with any complex and multisystem disorder, individuals with PS benefit from a coordinated and multidisciplinary clinical approach tailored to the individual's specific needs and manifestations.Overgrowth is an ongoing issue for many individuals with PS. The management is complex and highly dependent on the nature of the overgrowth, which can vary substantially.For overgrowth of tubular bones, epiphysiostasis and epiphysiodesis should be the mainstays of management. One intervention that the authors have found to be detrimental to individuals with PS is distraction osteotomy (so-
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. multisystem disorder, individuals with PS benefit from a coordinated and multidisciplinary clinical approach tailored to the individual's specific needs and manifestations.Overgrowth is an ongoing issue for many individuals with PS. The management is complex and highly dependent on the nature of the overgrowth, which can vary substantially.For overgrowth of tubular bones, epiphysiostasis and epiphysiodesis should be the mainstays of management. One intervention that the authors have found to be detrimental to individuals with PS is distraction osteotomy (so-called Ilizarov procedure) performed on the normal (shorter) limbs. Readers are referred to a review and conference report for more details on this complex issue .The skeletal overgrowth of PS can result in significant biomechanical and functional compromise. Because of this, ongoing and comprehensive rehabilitation medicine care, including physical and occupational therapy, is important for many individuals. In addition, many individuals with PS develop substantial needs for custom-designed footwear or orthotics due to leg-length
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. distraction osteotomy (so-called Ilizarov procedure) performed on the normal (shorter) limbs. Readers are referred to a review and conference report for more details on this complex issue .The skeletal overgrowth of PS can result in significant biomechanical and functional compromise. Because of this, ongoing and comprehensive rehabilitation medicine care, including physical and occupational therapy, is important for many individuals. In addition, many individuals with PS develop substantial needs for custom-designed footwear or orthotics due to leg-length inequality or plantar CCTNs.Refer to an orthopedist if scoliosis is identified on clinical and/or radiographic examination. Scoliosis surgery is high-risk in individuals with PS. The authors are aware of individuals who have died from DVT and PE, with prophylactic anticoagulation. In spite of this risk, such surgery is indicated because the progressive nature of the scoliosis can lead to fatal restrictive lung disease. Scoliosis in individuals with PS can advance extremely rapidly, and attentive and frequent monitoring is
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. due to leg-length inequality or plantar CCTNs.Refer to an orthopedist if scoliosis is identified on clinical and/or radiographic examination. Scoliosis surgery is high-risk in individuals with PS. The authors are aware of individuals who have died from DVT and PE, with prophylactic anticoagulation. In spite of this risk, such surgery is indicated because the progressive nature of the scoliosis can lead to fatal restrictive lung disease. Scoliosis in individuals with PS can advance extremely rapidly, and attentive and frequent monitoring is warranted .Cerebriform connective tissue nevi (CCTN). Individuals with PS who develop large plantar CCTNs should receive regular dermatologic care and attention to manage malodor (a potential complication of difficulty with cleanliness of the deepening of the sulci in late adolescence) and other concerns, such as pressure ulcerations. Large plantar CCTNs can also contribute to problems with shoe fit and often warrant pedorthic intervention as mentioned above. Surgical removal of a CCT
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. tive and frequent monitoring is warranted .Cerebriform connective tissue nevi (CCTN). Individuals with PS who develop large plantar CCTNs should receive regular dermatologic care and attention to manage malodor (a potential complication of difficulty with cleanliness of the deepening of the sulci in late adolescence) and other concerns, such as pressure ulcerations. Large plantar CCTNs can also contribute to problems with shoe fit and often warrant pedorthic intervention as mentioned above. Surgical removal of a CCTN has been successfully accomplished in at least two individuals.Overgrowth of lipomatous tissue / lipoatrophy. Management of the overgrowth of adipose tissue is challenging because the areas of adipose overgrowth are not encapsulated and discrete (in contrast to lipomas) and, therefore, can be difficult to resect and commonly regrow after surgical debulking. The authors generally recommend open surgical approaches over liposuction because the highly vascularized lipomatous overgrowth in some individuals can
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. Surgical removal of a CCTN has been successfully accomplished in at least two individuals.Overgrowth of lipomatous tissue / lipoatrophy. Management of the overgrowth of adipose tissue is challenging because the areas of adipose overgrowth are not encapsulated and discrete (in contrast to lipomas) and, therefore, can be difficult to resect and commonly regrow after surgical debulking. The authors generally recommend open surgical approaches over liposuction because the highly vascularized lipomatous overgrowth in some individuals can result in difficult-to-control hemorrhaging and/or chronically weeping lymphatics.Deep vein thrombosis (DVT) and pulmonary embolism (PE). The authors recommend emergent evaluation of individuals who develop symptoms of DVT (e.g., palpable subcutaneous rope-like mass, swelling, erythema, pain, and distal venous congestion) or PE (e.g., shortness of breath, chest pain, and cough which may include hemoptysis). Because individuals
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. overgrowth in some individuals can result in difficult-to-control hemorrhaging and/or chronically weeping lymphatics.Deep vein thrombosis (DVT) and pulmonary embolism (PE). The authors recommend emergent evaluation of individuals who develop symptoms of DVT (e.g., palpable subcutaneous rope-like mass, swelling, erythema, pain, and distal venous congestion) or PE (e.g., shortness of breath, chest pain, and cough which may include hemoptysis). Because individuals with PE can be asymptomatic, it is recommended that an individual with a DVT be evaluated for PE regardless of symptoms.Evaluation for DVTs. In the absence of cardiopulmonary compromise, consider the D-dimer assay and/or ultrasonographic evaluation.Evaluation of PE. High-resolution chest CT (so called spiral CT) with contrast is recommended. Ventilation-perfusion nuclear medicine scanning may be appropriate in some individuals.Treatment of DVT and PE should follow recommended anticoagulation guidelines for these disorders. The
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. optysis). Because individuals with PE can be asymptomatic, it is recommended that an individual with a DVT be evaluated for PE regardless of symptoms.Evaluation for DVTs. In the absence of cardiopulmonary compromise, consider the D-dimer assay and/or ultrasonographic evaluation.Evaluation of PE. High-resolution chest CT (so called spiral CT) with contrast is recommended. Ventilation-perfusion nuclear medicine scanning may be appropriate in some individuals.Treatment of DVT and PE should follow recommended anticoagulation guidelines for these disorders. The authors recommend hematologic evaluation and consultation for consideration of anticoagulant prophylaxis for individuals undergoing surgery or other procedures that may predispose to DVT/PE.Tumors. It is impractical to screen for tumors with imaging in individuals with PS because the tumors are so heterogeneous. Instead, a primary care clinician should evaluate the individuals regularly (every 6-12 months) and elicit signs and symptoms of malignancy (e.g., pain, unexpected growths, signs of obstruction or compression). If
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. for these disorders. The authors recommend hematologic evaluation and consultation for consideration of anticoagulant prophylaxis for individuals undergoing surgery or other procedures that may predispose to DVT/PE.Tumors. It is impractical to screen for tumors with imaging in individuals with PS because the tumors are so heterogeneous. Instead, a primary care clinician should evaluate the individuals regularly (every 6-12 months) and elicit signs and symptoms of malignancy (e.g., pain, unexpected growths, signs of obstruction or compression). If these are elicited, an imaging evaluation of that organ system should be undertaken.Bullous pulmonary disease. Pulmonary evaluation is recommended for individuals with bullous pulmonary disease, and resection of large bullous lesions may be indicated in some individuals. Bullous disease in the context of scoliosis can pose significant and complex challenges for appropriate management.Psychometric and learning evaluation. Developmental evaluation for consideration of intervention or special education for those individuals with developmental delays is indicated.Psychosocial issues. Psychosocial counseling is certainly warranted in most instances.
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. or compression). If these are elicited, an imaging evaluation of that organ system should be undertaken.Bullous pulmonary disease. Pulmonary evaluation is recommended for individuals with bullous pulmonary disease, and resection of large bullous lesions may be indicated in some individuals. Bullous disease in the context of scoliosis can pose significant and complex challenges for appropriate management.Psychometric and learning evaluation. Developmental evaluation for consideration of intervention or special education for those individuals with developmental delays is indicated.Psychosocial issues. Psychosocial counseling is certainly warranted in most instances. Although PS is exceedingly rare, a robust support group infrastructure exists and many families find this very helpful (see Resources).SurveillanceIndividualized surveillance plans for the skeletal, pulmonary, soft-tissue, and other manifestations of PS should be developed according to the individual's specific needs.Because of the predisposition to a range of tumors (most of which are benign) individuals with PS should be monitored by their primary care provider with regular evaluations including a directed medical history and examination;
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. warranted in most instances. Although PS is exceedingly rare, a robust support group infrastructure exists and many families find this very helpful (see Resources).SurveillanceIndividualized surveillance plans for the skeletal, pulmonary, soft-tissue, and other manifestations of PS should be developed according to the individual's specific needs.Because of the predisposition to a range of tumors (most of which are benign) individuals with PS should be monitored by their primary care provider with regular evaluations including a directed medical history and examination; periodic imaging is not indicated.Agents/Circumstances to AvoidMedications that increase the risk of DVT or are procoagulant should be avoided. Medications that increase growth (e.g., androgenic steroids or growth hormone) should be avoided.Evaluation of Relatives at RiskBecause PS is not inherited, relatives are not at increased risk and do not require evaluation.Pregnancy ManagementThere are no data on the management of pregnancy in women with PS. Pregnancy presents theoretic risks,
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. medical history and examination; periodic imaging is not indicated.Agents/Circumstances to AvoidMedications that increase the risk of DVT or are procoagulant should be avoided. Medications that increase growth (e.g., androgenic steroids or growth hormone) should be avoided.Evaluation of Relatives at RiskBecause PS is not inherited, relatives are not at increased risk and do not require evaluation.Pregnancy ManagementThere are no data on the management of pregnancy in women with PS. Pregnancy presents theoretic risks, especially the risk of thrombosis of the pelvic veins.Therapies Under InvestigationSearch ClinicalTrials.gov in the US and www.ClinicalTrialsRegister.eu in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK99495/
JOqrnDM
Proteus Syndrome
C0085261
31,761
proteus syndrome. presents theoretic risks, especially the risk of thrombosis of the pelvic veins.Therapies Under InvestigationSearch ClinicalTrials.gov in the US and www.ClinicalTrialsRegister.eu in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. SummaryClinical characteristics.The spectrum of propionic acidemia (PA) ranges from neonatal-onset to late-onset disease.Neonatal-onset PA, the most common form, is characterized by a healthy newborn with poor feeding and decreased arousal in the first few days of life, followed by progressive encephalopathy of unexplained origin. Without prompt diagnosis and management, this is followed by progressive encephalopathy manifesting as lethargy, seizures, or coma that can result in death. It is frequently accompanied by metabolic acidosis with anion gap, lactic acidosis, ketonuria, hypoglycemia, hyperammonemia, and cytopenias.Individuals with late-onset PA may remain asymptomatic and suffer a metabolic crisis under catabolic stress (e.g., illness, surgery, fasting) or may experience a more insidious onset with the development of multiorgan complications including vomiting, protein intolerance, failure to thrive, hypotonia, developmental delays or regression, movement disorders, or cardiomyopathy.Isolated cardiomyopathy
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. accompanied by metabolic acidosis with anion gap, lactic acidosis, ketonuria, hypoglycemia, hyperammonemia, and cytopenias.Individuals with late-onset PA may remain asymptomatic and suffer a metabolic crisis under catabolic stress (e.g., illness, surgery, fasting) or may experience a more insidious onset with the development of multiorgan complications including vomiting, protein intolerance, failure to thrive, hypotonia, developmental delays or regression, movement disorders, or cardiomyopathy.Isolated cardiomyopathy can be observed on rare occasion in the absence of clinical metabolic decompensation or neurocognitive deficits.Manifestations of neonatal and late-onset PA over time can include growth impairment, intellectual disability, seizures, basal ganglia lesions, pancreatitis, and cardiomyopathy. Other rarely reported complications include optic atrophy, hearing loss, premature ovarian insufficiency, and chronic renal failure.Diagnosis/testing.PA is caused by deficiency of propionyl-CoA carboxylase (PCC), the enzyme that catalyzes the conversion of propionyl
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. , or cardiomyopathy.Isolated cardiomyopathy can be observed on rare occasion in the absence of clinical metabolic decompensation or neurocognitive deficits.Manifestations of neonatal and late-onset PA over time can include growth impairment, intellectual disability, seizures, basal ganglia lesions, pancreatitis, and cardiomyopathy. Other rarely reported complications include optic atrophy, hearing loss, premature ovarian insufficiency, and chronic renal failure.Diagnosis/testing.PA is caused by deficiency of propionyl-CoA carboxylase (PCC), the enzyme that catalyzes the conversion of propionyl-CoA to methylmalonyl-CoA. Newborns with PA tested by expanded newborn screening have elevated C3 (propionylcarnitine). Testing of urine organic acids in persons who are symptomatic or those detected by newborn screening reveals elevated 3-hydroxypropionate and the presence of methylcitrate, tiglylglycine, propionylglycine, and lactic acid. Testing of plasma amino acids reveals elevated glycine. Confirmation of the diagnosis relies on detection of biallelic pathogenic variants in PCC
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. catalyzes the conversion of propionyl-CoA to methylmalonyl-CoA. Newborns with PA tested by expanded newborn screening have elevated C3 (propionylcarnitine). Testing of urine organic acids in persons who are symptomatic or those detected by newborn screening reveals elevated 3-hydroxypropionate and the presence of methylcitrate, tiglylglycine, propionylglycine, and lactic acid. Testing of plasma amino acids reveals elevated glycine. Confirmation of the diagnosis relies on detection of biallelic pathogenic variants in PCCA or PCCB or of deficient PCC enzymatic activity. In individuals with equivocal molecular genetic test results, a combination of enzymatic and molecular diagnostics may be necessary.Management.Treatment of manifestations: The treatment of individuals with acutely decompensated PA is a medical emergency: treat precipitating factors such as infection, dehydration, vomiting; reverse catabolism by providing intravenous glucose and lipids; manage protein intake to reduce propiogenic precursors; remove toxic compounds using nitrogen scavenger medications, extracorporeal detoxification, and/or
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. allelic pathogenic variants in PCCA or PCCB or of deficient PCC enzymatic activity. In individuals with equivocal molecular genetic test results, a combination of enzymatic and molecular diagnostics may be necessary.Management.Treatment of manifestations: The treatment of individuals with acutely decompensated PA is a medical emergency: treat precipitating factors such as infection, dehydration, vomiting; reverse catabolism by providing intravenous glucose and lipids; manage protein intake to reduce propiogenic precursors; remove toxic compounds using nitrogen scavenger medications, extracorporeal detoxification, and/or intravenous carnitine; transfer to a center with biochemical genetics expertise and the ability to support urgent hemodialysis, especially if hyperammonemia is present.Prevention of primary manifestations: Individualized dietary management should be directed by an experienced physician and metabolic dietician to control the intake of propiogenic substrates and to guide increased caloric intake during illness to prevent catabolism. G-tube placement is an effective strategy to facilitate the administration of medications and nutrition during acute decompensations and to improve adherence in chronic management
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. extracorporeal detoxification, and/or intravenous carnitine; transfer to a center with biochemical genetics expertise and the ability to support urgent hemodialysis, especially if hyperammonemia is present.Prevention of primary manifestations: Individualized dietary management should be directed by an experienced physician and metabolic dietician to control the intake of propiogenic substrates and to guide increased caloric intake during illness to prevent catabolism. G-tube placement is an effective strategy to facilitate the administration of medications and nutrition during acute decompensations and to improve adherence in chronic management of PA.Medications may include: L-carnitine supplementation to enhance excretion of propionic acid and oral metronidazole to reduce propionate production by gut bacteria. Orthotopic liver transplantation (OLT) may be indicated in those with frequent metabolic decompensations, uncontrollable hyperammonemia, and/or poor growth.Prevention of secondary complications: Consistent evaluation of the protein intake, depending on age, gender, severity of disorder and presence of other factors such as intercurrent illness, surgery, level of
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. to improve adherence in chronic management of PA.Medications may include: L-carnitine supplementation to enhance excretion of propionic acid and oral metronidazole to reduce propionate production by gut bacteria. Orthotopic liver transplantation (OLT) may be indicated in those with frequent metabolic decompensations, uncontrollable hyperammonemia, and/or poor growth.Prevention of secondary complications: Consistent evaluation of the protein intake, depending on age, gender, severity of disorder and presence of other factors such as intercurrent illness, surgery, level of physical activity, and growth spurts to avoid insufficient or excessive protein restriction. Excessive protein restriction can result in deficiency of essential amino acids and impaired growth, as well as catabolism-induced metabolic decompensation.Surveillance: Monitor closely patients with a catabolic stressor (fasting, fever, illness, injury, and surgery) to prevent and/or detect and manage metabolic decompensations early. Regularly assess: (1) growth, nutritional status, feeding ability, psychomotor development; (2) vision
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. illness, surgery, level of physical activity, and growth spurts to avoid insufficient or excessive protein restriction. Excessive protein restriction can result in deficiency of essential amino acids and impaired growth, as well as catabolism-induced metabolic decompensation.Surveillance: Monitor closely patients with a catabolic stressor (fasting, fever, illness, injury, and surgery) to prevent and/or detect and manage metabolic decompensations early. Regularly assess: (1) growth, nutritional status, feeding ability, psychomotor development; (2) vision and hearing (3) cardiac function for signs of cardiomyopathy; (4) metabolic status by monitoring urine organic acids and plasma amino acids; (5) complete blood count; (6) renal function.Agents/circumstances to avoid: Prolonged fasting, catabolic stressors, and excessive protein intake. Lactated Ringer’s solution is not recommended in patients with organic acidemias. In patients with QT abnormalities, avoid medications that can prolong the QT interval. Neuroleptic antiemetics (e.
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. development; (2) vision and hearing (3) cardiac function for signs of cardiomyopathy; (4) metabolic status by monitoring urine organic acids and plasma amino acids; (5) complete blood count; (6) renal function.Agents/circumstances to avoid: Prolonged fasting, catabolic stressors, and excessive protein intake. Lactated Ringer’s solution is not recommended in patients with organic acidemias. In patients with QT abnormalities, avoid medications that can prolong the QT interval. Neuroleptic antiemetics (e.g., promethazine) can mask symptoms of progressive encephalopathy and are best avoided.Evaluation of relatives at risk: Testing of at-risk sibs of a patient is warranted to allow for early diagnosis and treatment.Genetic counseling.Propionic acidemia is inherited in an autosomal recessive manner. At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. Neuroleptic antiemetics (e.g., promethazine) can mask symptoms of progressive encephalopathy and are best avoided.Evaluation of relatives at risk: Testing of at-risk sibs of a patient is warranted to allow for early diagnosis and treatment.Genetic counseling.Propionic acidemia is inherited in an autosomal recessive manner. At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected and not a carrier. Carrier testing for at-risk relatives and prenatal testing for pregnancies at increased risk are possible if the pathogenic variants in the family are known.DiagnosisPropionic acidemia (PA) is caused by deficiency of the mitochondrial multimeric enzyme propionyl-CoA carboxylase that catalyzes the conversion of propionyl-CoA to D-methylmalonyl-CoA. The enzyme is composed of α- and β-subunits encoded by their respective genes, PCCA and PCC
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. 25% chance of being unaffected and not a carrier. Carrier testing for at-risk relatives and prenatal testing for pregnancies at increased risk are possible if the pathogenic variants in the family are known.DiagnosisPropionic acidemia (PA) is caused by deficiency of the mitochondrial multimeric enzyme propionyl-CoA carboxylase that catalyzes the conversion of propionyl-CoA to D-methylmalonyl-CoA. The enzyme is composed of α- and β-subunits encoded by their respective genes, PCCA and PCCB. Deficient activity of propionyl-CoA carboxylase results in accumulation of propionic acid and propionyl-CoA related metabolites, which can be detected biochemically. In many countries, infants at risk for PA can be detected via newborn screening (NBS), although symptoms may be evident in the infant before NBS results are available. Clinical manifestations of PA are often nonspecific and age of onset is variable.Suggestive FindingsPropionic acidemia (PA) should be suspected in individuals with any of
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. genes, PCCA and PCCB. Deficient activity of propionyl-CoA carboxylase results in accumulation of propionic acid and propionyl-CoA related metabolites, which can be detected biochemically. In many countries, infants at risk for PA can be detected via newborn screening (NBS), although symptoms may be evident in the infant before NBS results are available. Clinical manifestations of PA are often nonspecific and age of onset is variable.Suggestive FindingsPropionic acidemia (PA) should be suspected in individuals with any of the following presentations.Neonatal-onset propionic acidemia (PA) is the most common clinical form of PA. In the first few days of life, infants present with:LethargyPoor feedingVomitingHypotoniaWithout treatment, this can progress to encephalopathy and cardiorespiratory failure.Symptoms may be evident in the infant before NBS results are available.Late-onset PA can present with a variety of concerns including:Developmental delayIntellectual disabilityFailure
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. suspected in individuals with any of the following presentations.Neonatal-onset propionic acidemia (PA) is the most common clinical form of PA. In the first few days of life, infants present with:LethargyPoor feedingVomitingHypotoniaWithout treatment, this can progress to encephalopathy and cardiorespiratory failure.Symptoms may be evident in the infant before NBS results are available.Late-onset PA can present with a variety of concerns including:Developmental delayIntellectual disabilityFailure to thriveChronic gastrointestinal complaintsProtein intoleranceAcute psychosisHypotoniaMovement disorders such as dystonia and choreoathetosisAcute decompensation can be precipitated by metabolic stressors including infection, injury, or surgery.Cardiomyopathy can occur as an apparently isolated clinical phenomenon in previously healthy individuals without documented episodes of metabolic decompensation or neurocognitive deficits .TestingNewborn screening (NBS). Detection of PA in the neonatal period is possible using acylcarnitine analysis by tandem mass spectrometry
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. ctual disabilityFailure to thriveChronic gastrointestinal complaintsProtein intoleranceAcute psychosisHypotoniaMovement disorders such as dystonia and choreoathetosisAcute decompensation can be precipitated by metabolic stressors including infection, injury, or surgery.Cardiomyopathy can occur as an apparently isolated clinical phenomenon in previously healthy individuals without documented episodes of metabolic decompensation or neurocognitive deficits .TestingNewborn screening (NBS). Detection of PA in the neonatal period is possible using acylcarnitine analysis by tandem mass spectrometry (MS/MS) on dried blood spots.Acylcarnitine analysis reveals elevated propionylcarnitine (C3).Secondary markers including methionine, C3/C2, and C3/C16 ratios can be helpful to increase diagnostic accuracy .Biochemical analysis. Deficiency of propionyl-CoA carboxylase results in accumulation of propionic acid and propionyl-CoA related metabolites in plasma and urine, causing a wide range of laboratory test abnormalities (Figure 1).Figure 1. Metabolic pathway. Prop
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. nitine analysis by tandem mass spectrometry (MS/MS) on dried blood spots.Acylcarnitine analysis reveals elevated propionylcarnitine (C3).Secondary markers including methionine, C3/C2, and C3/C16 ratios can be helpful to increase diagnostic accuracy .Biochemical analysis. Deficiency of propionyl-CoA carboxylase results in accumulation of propionic acid and propionyl-CoA related metabolites in plasma and urine, causing a wide range of laboratory test abnormalities (Figure 1).Figure 1. Metabolic pathway. Propionyl-CoA carboxylase (PCC) catalyzes the conversion of propionyl-CoA to methylmalonyl-CoA, which enters the Krebs cycle via succinyl-CoA. Sources of propionate include: valine, isoleucine, threonine, methionine, odd-chain fatty (more...)Biochemical findings in propionic acidemia include:Plasma acylcarnitine profile: elevated propionylcarnitine (C3)Urine organic acids:Elevated 3-hydroxypropionatePresence of:Methyl
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. 1. Metabolic pathway. Propionyl-CoA carboxylase (PCC) catalyzes the conversion of propionyl-CoA to methylmalonyl-CoA, which enters the Krebs cycle via succinyl-CoA. Sources of propionate include: valine, isoleucine, threonine, methionine, odd-chain fatty (more...)Biochemical findings in propionic acidemia include:Plasma acylcarnitine profile: elevated propionylcarnitine (C3)Urine organic acids:Elevated 3-hydroxypropionatePresence of:MethylcitrateTiglylglycinePropionylglycineLactic acidPlasma amino acids: elevated glycineCommon laboratory abnormalities during acute decompensation include:High-anion gap metabolic acidosisLactic acidosisElevated plasma and urinary ketonesLow to normal blood glucose concentrationHyperammonemiaNeutropenia, anemia, and thrombocytopeniaEstablishing the DiagnosisIn a proband who has the clinical, laboratory, and biochemical findings reviewed above and in Figure 2, the diagnosis of PA is established using
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. sence of:MethylcitrateTiglylglycinePropionylglycineLactic acidPlasma amino acids: elevated glycineCommon laboratory abnormalities during acute decompensation include:High-anion gap metabolic acidosisLactic acidosisElevated plasma and urinary ketonesLow to normal blood glucose concentrationHyperammonemiaNeutropenia, anemia, and thrombocytopeniaEstablishing the DiagnosisIn a proband who has the clinical, laboratory, and biochemical findings reviewed above and in Figure 2, the diagnosis of PA is established using the following strategies.Figure 2. Immediate management and testing algorithm to be pursued simultaneously after the clinical or laboratory suspicion of PA I. Identification of biallelic pathogenic variants in PCCA or PCCB on molecular genetic testing (see Table 1). Molecular testing approaches can include serial single-gene testing, use of a multigene panel, and more comprehensive genomic testing:Serial single-gene testing can be considered if (1) mutation of a particular gene accounts for a large
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. diagnosis of PA is established using the following strategies.Figure 2. Immediate management and testing algorithm to be pursued simultaneously after the clinical or laboratory suspicion of PA I. Identification of biallelic pathogenic variants in PCCA or PCCB on molecular genetic testing (see Table 1). Molecular testing approaches can include serial single-gene testing, use of a multigene panel, and more comprehensive genomic testing:Serial single-gene testing can be considered if (1) mutation of a particular gene accounts for a large proportion of the condition or (2) factors such as clinical findings, laboratory findings, and ancestry indicate that mutation of a particular gene is most likely.For PA, neither gene is more common and there are no characteristic findings to distinguish between PCCA- and PCCB-associated PA.In instances where this testing approach is the only one available, sequence analysis of either PCCA or PCCB is performed first, followed by gene-targeted deletion/duplication analysis if only one
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. particular gene accounts for a large proportion of the condition or (2) factors such as clinical findings, laboratory findings, and ancestry indicate that mutation of a particular gene is most likely.For PA, neither gene is more common and there are no characteristic findings to distinguish between PCCA- and PCCB-associated PA.In instances where this testing approach is the only one available, sequence analysis of either PCCA or PCCB is performed first, followed by gene-targeted deletion/duplication analysis if only one or no pathogenic variant is found.A multigene panel that includes PCCA and PCCB and other genes of interest (see Differential Diagnosis) may also be considered. Note: (1) The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and are likely to change over time. (2) Some multigene panels may include genes not associated with the condition discussed in this GeneReview; thus, clinicians need to
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. /duplication analysis if only one or no pathogenic variant is found.A multigene panel that includes PCCA and PCCB and other genes of interest (see Differential Diagnosis) may also be considered. Note: (1) The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and are likely to change over time. (2) Some multigene panels may include genes not associated with the condition discussed in this GeneReview; thus, clinicians need to determine which multigene panel is most likely to identify the genetic cause of the condition at the most reasonable cost while limiting identification of variants of uncertain significance and pathogenic variants in genes that do not explain the underlying phenotype. (3) In some laboratories, panel options may include a custom laboratory-designed panel and/or custom phenotype-focused exome analysis that includes genes specified by the clinician. (4) Methods used in a panel may include sequence analysis, deletion/duplication analysis,
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. ; thus, clinicians need to determine which multigene panel is most likely to identify the genetic cause of the condition at the most reasonable cost while limiting identification of variants of uncertain significance and pathogenic variants in genes that do not explain the underlying phenotype. (3) In some laboratories, panel options may include a custom laboratory-designed panel and/or custom phenotype-focused exome analysis that includes genes specified by the clinician. (4) Methods used in a panel may include sequence analysis, deletion/duplication analysis, and/or other non-sequencing-based tests.For an introduction to multigene panels click here. More detailed information for clinicians ordering genetic tests can be found here.More comprehensive genomic testing (when available) including exome sequencing and genome sequencing may be considered if serial single-gene testing (and/or use of a multigene panel that includes PCCA and PCCB) fails to confirm a diagnosis in an individual with features of propionic acidemia. Such testing may provide
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. , deletion/duplication analysis, and/or other non-sequencing-based tests.For an introduction to multigene panels click here. More detailed information for clinicians ordering genetic tests can be found here.More comprehensive genomic testing (when available) including exome sequencing and genome sequencing may be considered if serial single-gene testing (and/or use of a multigene panel that includes PCCA and PCCB) fails to confirm a diagnosis in an individual with features of propionic acidemia. Such testing may provide or suggest a diagnosis not previously considered (e.g., mutation of a different gene or genes that results in a similar clinical presentation). For an introduction to comprehensive genomic testing click here. More detailed information for clinicians ordering genomic testing can be found here.Table 1. Molecular Genetic Testing Used in Propionic AcidemiaView in own windowGene 1Proportion of PA Attributed to Pathogenic Variants in GeneProportion of Pathogenic Variants 2 Detected by Method 3Sequence analysis 4Gene-
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. emia. Such testing may provide or suggest a diagnosis not previously considered (e.g., mutation of a different gene or genes that results in a similar clinical presentation). For an introduction to comprehensive genomic testing click here. More detailed information for clinicians ordering genomic testing can be found here.Table 1. Molecular Genetic Testing Used in Propionic AcidemiaView in own windowGene 1Proportion of PA Attributed to Pathogenic Variants in GeneProportion of Pathogenic Variants 2 Detected by Method 3Sequence analysis 4Gene-targeted deletion/duplication analysis 5PCCA50%78%18% 6PCCB50%97%3% 71. See Table A. Genes and Databases for chromosome locus and protein.2. See Molecular Genetics for information on allelic variants detected in this gene.3. Kraus et al reported no identifiable pathogenic variants in 7% (4/54) and one identifiable variant in 4% (2/54) of individuals with propionic acidemia. Some of
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. equence analysis 4Gene-targeted deletion/duplication analysis 5PCCA50%78%18% 6PCCB50%97%3% 71. See Table A. Genes and Databases for chromosome locus and protein.2. See Molecular Genetics for information on allelic variants detected in this gene.3. Kraus et al reported no identifiable pathogenic variants in 7% (4/54) and one identifiable variant in 4% (2/54) of individuals with propionic acidemia. Some of the variants may have escaped detection by existing sequencing methods, but could have been detected by copy number analysis . Desviat et al reported that only 1.5% of individuals with PCCA-related PA could not be characterized molecularly, when analyzed using both sequencing and copy number analysis .4. Sequence analysis detects variants that are benign, likely benign, of uncertain significance, likely pathogenic, or pathogenic. Variants may include small intragenic deletions/insertions and missense, nonsense
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. propionic acidemia. Some of the variants may have escaped detection by existing sequencing methods, but could have been detected by copy number analysis . Desviat et al reported that only 1.5% of individuals with PCCA-related PA could not be characterized molecularly, when analyzed using both sequencing and copy number analysis .4. Sequence analysis detects variants that are benign, likely benign, of uncertain significance, likely pathogenic, or pathogenic. Variants may include small intragenic deletions/insertions and missense, nonsense, and splice site variants; typically, exon or whole-gene deletions/duplications are not detected. For issues to consider in interpretation of sequence analysis results, click here.5. Gene-targeted deletion/duplication analysis detects intragenic deletions or duplications. Methods used may include quantitative PCR, long-range PCR, multiplex ligation-dependent probe amplification (MLPA), and a gene-targeted microarray designed to detect single exon deletions or duplications.6. Exon deletions account for
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. /insertions and missense, nonsense, and splice site variants; typically, exon or whole-gene deletions/duplications are not detected. For issues to consider in interpretation of sequence analysis results, click here.5. Gene-targeted deletion/duplication analysis detects intragenic deletions or duplications. Methods used may include quantitative PCR, long-range PCR, multiplex ligation-dependent probe amplification (MLPA), and a gene-targeted microarray designed to detect single exon deletions or duplications.6. Exon deletions account for to ~20% of PCCA disease-causing alleles .7. Three PCCB large-deletion alleles have been described .II. An alternative approach involves the assay of propionyl-CoA carboxylase (PCC) enzyme activity in lymphocytes or cultured skin fibroblasts followed by molecular diagnosis . In individuals with equivocal molecular genetic test results, a combination of enzymatic and molecular diagnostics may be necessary.Clinical CharacteristicsClinical DescriptionPropionic acidemia presents with a wide spectrum of symptoms and age of
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. 6. Exon deletions account for to ~20% of PCCA disease-causing alleles .7. Three PCCB large-deletion alleles have been described .II. An alternative approach involves the assay of propionyl-CoA carboxylase (PCC) enzyme activity in lymphocytes or cultured skin fibroblasts followed by molecular diagnosis . In individuals with equivocal molecular genetic test results, a combination of enzymatic and molecular diagnostics may be necessary.Clinical CharacteristicsClinical DescriptionPropionic acidemia presents with a wide spectrum of symptoms and age of onset. The onset of symptoms in PA varies depending on several factors including residual enzymatic activity, intake of propiogenic precursors, and the occurrence of catabolic stressors. See Table 3a (pdf) and Table 3b (pdf) for a summary of major clinical findings in propionic acidemia (PA) and the reported frequency of symptoms.Perinatal course. Reported maternal prenatal course, gestational age, and birth length, weight, and head circumference are similar to what is reported for unaffected infants
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. spectrum of symptoms and age of onset. The onset of symptoms in PA varies depending on several factors including residual enzymatic activity, intake of propiogenic precursors, and the occurrence of catabolic stressors. See Table 3a (pdf) and Table 3b (pdf) for a summary of major clinical findings in propionic acidemia (PA) and the reported frequency of symptoms.Perinatal course. Reported maternal prenatal course, gestational age, and birth length, weight, and head circumference are similar to what is reported for unaffected infants . Increased frequency of miscarriages of affected fetuses is possible .Neonatal onset PA. A typical presentation of PA in the neonatal period is characterized by a healthy newborn with poor feeding and decreased arousal in the first few days of life, followed by progressive encephalopathy of unexplained origin. Without prompt diagnosis and management, neonates can develop progressive encephalopathy manifesting as lethargy, seizures, or coma that can result in death (see Table 2). Most individuals eventually diagnosed with PA become symptomatic in
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. what is reported for unaffected infants . Increased frequency of miscarriages of affected fetuses is possible .Neonatal onset PA. A typical presentation of PA in the neonatal period is characterized by a healthy newborn with poor feeding and decreased arousal in the first few days of life, followed by progressive encephalopathy of unexplained origin. Without prompt diagnosis and management, neonates can develop progressive encephalopathy manifesting as lethargy, seizures, or coma that can result in death (see Table 2). Most individuals eventually diagnosed with PA become symptomatic in the first weeks of life, with 50%-60% exhibiting clinical signs at the time of the newborn screen report .Table 2. Features of Neonatal-Onset Propionic AcidemiaView in own windowClinical FeaturesLaboratory FindingsPoor feedingVomitingIrritabilityLethargyProgressive encephalopathySeizuresComaRespiratory failureHigh anion-gap metabolic acidosisKetonuriaHyperammonemia (>90%)HypoglycemiaEle
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. diagnosed with PA become symptomatic in the first weeks of life, with 50%-60% exhibiting clinical signs at the time of the newborn screen report .Table 2. Features of Neonatal-Onset Propionic AcidemiaView in own windowClinical FeaturesLaboratory FindingsPoor feedingVomitingIrritabilityLethargyProgressive encephalopathySeizuresComaRespiratory failureHigh anion-gap metabolic acidosisKetonuriaHyperammonemia (>90%)HypoglycemiaElevated 3-OH propionic acid & methylcitric acidHyperglycinemiaElevated propionylcarnitineAnemiaLeukopeniaThrombocytopeniaSee Table 3a (pdf) for a summary of the prevalence of major clinical findings during metabolic crisis in propionic acidemia.Following initial clinical and biochemical stabilization, individuals with neonatal-onset PA may develop a range of symptoms affecting different organ systems. See following and Table 3b (pdf).Late-onset PA.
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. ;90%)HypoglycemiaElevated 3-OH propionic acid & methylcitric acidHyperglycinemiaElevated propionylcarnitineAnemiaLeukopeniaThrombocytopeniaSee Table 3a (pdf) for a summary of the prevalence of major clinical findings during metabolic crisis in propionic acidemia.Following initial clinical and biochemical stabilization, individuals with neonatal-onset PA may develop a range of symptoms affecting different organ systems. See following and Table 3b (pdf).Late-onset PA. Residual activity of propionyl-CoA carboxylase may delay the onset of symptoms beyond the neonatal period.Individuals with late-onset PA may remain asymptomatic and suffer a metabolic crisis under catabolic stress (e.g., illness, surgery, fasting) or experience a more insidious onset with the development of multiorgan complications as summarized in Table 4. See also Table 3b.Table 4. Features of Late-Onset Propionic AcidemiaView in own windowClinical FeaturesLabora
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. .Late-onset PA. Residual activity of propionyl-CoA carboxylase may delay the onset of symptoms beyond the neonatal period.Individuals with late-onset PA may remain asymptomatic and suffer a metabolic crisis under catabolic stress (e.g., illness, surgery, fasting) or experience a more insidious onset with the development of multiorgan complications as summarized in Table 4. See also Table 3b.Table 4. Features of Late-Onset Propionic AcidemiaView in own windowClinical FeaturesLaboratory FindingsEncephalopathy, coma, and/or seizures precipitated by catabolic stressors (e.g., intercurrent illness, surgery)Vomiting, protein intolerance, failure to thrive, hypotonia, developmental regression, movement disordersIsolated cardiomyopathy 1 ± metabolic acidosis or hyperammonemiaElevated 3-OH propionic acid & methylcitric acidHyperglycinemiaMRI abnormalities including basal ganglia lesions 2 1. Lee et al 2. Broomfield et
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. windowClinical FeaturesLaboratory FindingsEncephalopathy, coma, and/or seizures precipitated by catabolic stressors (e.g., intercurrent illness, surgery)Vomiting, protein intolerance, failure to thrive, hypotonia, developmental regression, movement disordersIsolated cardiomyopathy 1 ± metabolic acidosis or hyperammonemiaElevated 3-OH propionic acid & methylcitric acidHyperglycinemiaMRI abnormalities including basal ganglia lesions 2 1. Lee et al 2. Broomfield et al Metabolic decompensations. Children with PA can develop episodic metabolic decompensations, especially in the first years of life. Acidosis, hyperammonemia, pancreatitis, metabolic stroke, cardiomyopathy, bone marrow suppression, seizures, and encephalopathy can accompany acutely deranged metabolism. These episodes can be life-threatening and are often precipitated by illnesses, infections, surgery, or any stress augmenting catabolism. Infectious complications (e.g., sepsis or bacterial meningitis) often accompany metabolic crises and
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. 2. Broomfield et al Metabolic decompensations. Children with PA can develop episodic metabolic decompensations, especially in the first years of life. Acidosis, hyperammonemia, pancreatitis, metabolic stroke, cardiomyopathy, bone marrow suppression, seizures, and encephalopathy can accompany acutely deranged metabolism. These episodes can be life-threatening and are often precipitated by illnesses, infections, surgery, or any stress augmenting catabolism. Infectious complications (e.g., sepsis or bacterial meningitis) often accompany metabolic crises and are the major contributors to mortality . The long-term cognitive outcome of individuals with PA is negatively correlated to the number of metabolic decompensations .Growth. Linear growth delay and deceleration of the head circumference may become evident with age and can be seen in both earlier- and late-onset groups . Failure to thrive may be exacerbated by malnutrition secondary to feeding difficulties, recurrent emesis, excessive protein restriction and potentially iatrogenic amino acid imbalances .Neurologic manifestations include developmental delay, developmental regression
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. often accompany metabolic crises and are the major contributors to mortality . The long-term cognitive outcome of individuals with PA is negatively correlated to the number of metabolic decompensations .Growth. Linear growth delay and deceleration of the head circumference may become evident with age and can be seen in both earlier- and late-onset groups . Failure to thrive may be exacerbated by malnutrition secondary to feeding difficulties, recurrent emesis, excessive protein restriction and potentially iatrogenic amino acid imbalances .Neurologic manifestations include developmental delay, developmental regression, intellectual disability, seizures, hypotonia, spasticity, and movement disorders . Developmental delays and neurologic dysfunction can be seen even in individuals without documented episodes of hyperammonemia or ketoacidosis . The prevalence of intellectual disability can vary between approximately 35% and 76% depending on the reported cohort .Seizures were reported in 13%-53% and EEG abnormalities in 40%-63% of Individuals with PA. Reported forms of seizures included infantile spasms, tonic-clonic,
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. include developmental delay, developmental regression, intellectual disability, seizures, hypotonia, spasticity, and movement disorders . Developmental delays and neurologic dysfunction can be seen even in individuals without documented episodes of hyperammonemia or ketoacidosis . The prevalence of intellectual disability can vary between approximately 35% and 76% depending on the reported cohort .Seizures were reported in 13%-53% and EEG abnormalities in 40%-63% of Individuals with PA. Reported forms of seizures included infantile spasms, tonic-clonic, tonic, myoclonic, atonic, absence, and focal . Seizures were one of the presenting features of the initial metabolic episode in 12%-26% of cases .Basal ganglia changes. Individuals with PA are predisposed to basal ganglia lesions, especially during episodes of acute encephalopathy or metabolic instability . Basal ganglia changes seen in 7%-56% of individuals may be preceded by an acute “stroke-like” episode and manifest as altered mental status, dystonia, choreoa
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. , tonic-clonic, tonic, myoclonic, atonic, absence, and focal . Seizures were one of the presenting features of the initial metabolic episode in 12%-26% of cases .Basal ganglia changes. Individuals with PA are predisposed to basal ganglia lesions, especially during episodes of acute encephalopathy or metabolic instability . Basal ganglia changes seen in 7%-56% of individuals may be preceded by an acute “stroke-like” episode and manifest as altered mental status, dystonia, choreoathetosis, or hemiplegia . The frequency of movement disorders in PA appears to be independent of the age of symptom onset .Psychiatric manifestations. The prevalence of other comorbidities such as attention deficit disorder, autism spectrum disorder, anxiety, and acute psychosis is incompletely characterized . Acute psychosis can be a presenting feature of PA in older individuals, especially in those not evaluated by newborn screen, thus warranting a high index of suspicion for this uncommon cause of psychosis in the general population .
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. , dystonia, choreoathetosis, or hemiplegia . The frequency of movement disorders in PA appears to be independent of the age of symptom onset .Psychiatric manifestations. The prevalence of other comorbidities such as attention deficit disorder, autism spectrum disorder, anxiety, and acute psychosis is incompletely characterized . Acute psychosis can be a presenting feature of PA in older individuals, especially in those not evaluated by newborn screen, thus warranting a high index of suspicion for this uncommon cause of psychosis in the general population .Brain MRI findings include delayed myelination, white matter changes, basal ganglia abnormalities, cerebellar hemorrhage, and cerebral atrophy . Clinically unstable individuals appear to be at higher risk of developing brain abnormalities. In a study of 17 PA individuals with clinical seizures, all had abnormal MRI findings and a history of more than ten metabolic decompensations . Magnetic resonance spectroscopy (MRS) can reveal decreased myoinositol, N-acetylaspartate and elevated Glx (glutamine, glutamate, and gamma-aminobutyric
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. psychosis in the general population .Brain MRI findings include delayed myelination, white matter changes, basal ganglia abnormalities, cerebellar hemorrhage, and cerebral atrophy . Clinically unstable individuals appear to be at higher risk of developing brain abnormalities. In a study of 17 PA individuals with clinical seizures, all had abnormal MRI findings and a history of more than ten metabolic decompensations . Magnetic resonance spectroscopy (MRS) can reveal decreased myoinositol, N-acetylaspartate and elevated Glx (glutamine, glutamate, and gamma-aminobutyric acid) peaks in basal ganglia .Cardiomyopathy has been recognized as a common complication of PA. Both dilated and hypertrophic cardiomyopathy have been reported . In the period between 2000 and 2015, its reported prevalence varied between 7% and 24% in various PA cohorts .Early clinical manifestations of cardiomyopathy include tachypnea, hepatomegaly, hypotension, tachycardia, or bradycardia.The mean age of onset of cardiomyopathy was seven years in a study by Romano et al .The age of PA diagnosis
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. glutamate, and gamma-aminobutyric acid) peaks in basal ganglia .Cardiomyopathy has been recognized as a common complication of PA. Both dilated and hypertrophic cardiomyopathy have been reported . In the period between 2000 and 2015, its reported prevalence varied between 7% and 24% in various PA cohorts .Early clinical manifestations of cardiomyopathy include tachypnea, hepatomegaly, hypotension, tachycardia, or bradycardia.The mean age of onset of cardiomyopathy was seven years in a study by Romano et al .The age of PA diagnosis, frequency of metabolic decompensation, and residual enzymatic activity do not correlate with presence/absence of cardiomyopathy in individuals with PA .Rarely, cardiomyopathy can occur as an apparently isolated clinical phenomenon in previously healthy individuals without documented episodes of metabolic decompensation or neurocognitive deficits .Cardiomyopathy can progress to cardiac failure and may be associated with sudden death .Cardiac rhythm abnormalities. A prolonged QT interval is often detected in individuals with PA . This can be associated with syncope, arrhythmia, and cardiac arrest .Gastrointestinal manifestations
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. .The age of PA diagnosis, frequency of metabolic decompensation, and residual enzymatic activity do not correlate with presence/absence of cardiomyopathy in individuals with PA .Rarely, cardiomyopathy can occur as an apparently isolated clinical phenomenon in previously healthy individuals without documented episodes of metabolic decompensation or neurocognitive deficits .Cardiomyopathy can progress to cardiac failure and may be associated with sudden death .Cardiac rhythm abnormalities. A prolonged QT interval is often detected in individuals with PA . This can be associated with syncope, arrhythmia, and cardiac arrest .Gastrointestinal manifestationsPancreatitis (reported in 3%-18% of individuals) may be recurrent and may present with anorexia, recurrent nausea, and abdominal pain . In some individuals recurrent pancreatitis can lead to insulin-dependent diabetes.Poor feeding and lack of appetite are common, affecting up to 76% of affected individuals .Emesis and diarrhea are commonly reported in individuals with PA, becoming a recurrent problem in approximately 6% .Liver issues include hepatomegaly, hypoalbuminemia, and
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. and cardiac arrest .Gastrointestinal manifestationsPancreatitis (reported in 3%-18% of individuals) may be recurrent and may present with anorexia, recurrent nausea, and abdominal pain . In some individuals recurrent pancreatitis can lead to insulin-dependent diabetes.Poor feeding and lack of appetite are common, affecting up to 76% of affected individuals .Emesis and diarrhea are commonly reported in individuals with PA, becoming a recurrent problem in approximately 6% .Liver issues include hepatomegaly, hypoalbuminemia, and abnormal liver function tests (ALT, AST, GGT, INR, and bilirubin) . The etiology of hepatic dysfunction has not been determined with certainty but may include the inherent metabolic derangement as well as cardiac dysfunction in individuals with cardiomyopathy.Renal abnormalities have been infrequently documented and are likely underreported. Examples have included impaired renal function , chronic renal insufficiency leading to renal transplant at age 42 years , and progressive kidney disease in the third decade of life .Hematologic abnormalities. Although anemia,
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. , hypoalbuminemia, and abnormal liver function tests (ALT, AST, GGT, INR, and bilirubin) . The etiology of hepatic dysfunction has not been determined with certainty but may include the inherent metabolic derangement as well as cardiac dysfunction in individuals with cardiomyopathy.Renal abnormalities have been infrequently documented and are likely underreported. Examples have included impaired renal function , chronic renal insufficiency leading to renal transplant at age 42 years , and progressive kidney disease in the third decade of life .Hematologic abnormalities. Although anemia, leukopenia, and thrombocytopenia are common, pancytopenia is seen less frequently, in 6%-15% of individuals . Myelodysplastic changes in the bone marrow are uncommon .Immune system. Early retrospective data suggested high frequency of recurrent infections seen in 60%-80% of affected individuals . Factors predisposing to infectious complications were likely diverse and included bone marrow suppression, immune dysfunction instigated by propionic acid metabolites, indwelling catheters (e.g., central lines), frequent hospitalizations
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. Hematologic abnormalities. Although anemia, leukopenia, and thrombocytopenia are common, pancytopenia is seen less frequently, in 6%-15% of individuals . Myelodysplastic changes in the bone marrow are uncommon .Immune system. Early retrospective data suggested high frequency of recurrent infections seen in 60%-80% of affected individuals . Factors predisposing to infectious complications were likely diverse and included bone marrow suppression, immune dysfunction instigated by propionic acid metabolites, indwelling catheters (e.g., central lines), frequent hospitalizations, and potential nutritional deficiencies caused by dietary modification. Although staphylococcal scalded skin syndrome and Candida skin infections were reported in the earlier literature , more recent natural history studies suggest that such complications are uncommon .Hypogammaglobulinemia, B-cell lymphopenia, decreased CD4 and CD8 counts, and abnormal CD4/CD8 ratio have been described . Hypogammaglobulinemia, reported in as many as 15% of affected individuals, has required treatment with immunoglobulin in some cases .Ophthalmologic
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. central lines), frequent hospitalizations, and potential nutritional deficiencies caused by dietary modification. Although staphylococcal scalded skin syndrome and Candida skin infections were reported in the earlier literature , more recent natural history studies suggest that such complications are uncommon .Hypogammaglobulinemia, B-cell lymphopenia, decreased CD4 and CD8 counts, and abnormal CD4/CD8 ratio have been described . Hypogammaglobulinemia, reported in as many as 15% of affected individuals, has required treatment with immunoglobulin in some cases .Ophthalmologic manifestations. Eye findings include dyschromatopsia, optic atrophy, scotomas, abnormal electroretinogram, visual evoked potentials, and optical coherent tomography. In addition, optic tract and cortical abnormalities have been occasionally noted .Optic neuropathy occurs in 11%-25% . The onset of optic neuropathy can be acute or insidious; further deterioration can occur during metabolic decompensations triggered by infections or surgery . The mean age of diagnosis is approximately 13 years (range 2-24
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. in some cases .Ophthalmologic manifestations. Eye findings include dyschromatopsia, optic atrophy, scotomas, abnormal electroretinogram, visual evoked potentials, and optical coherent tomography. In addition, optic tract and cortical abnormalities have been occasionally noted .Optic neuropathy occurs in 11%-25% . The onset of optic neuropathy can be acute or insidious; further deterioration can occur during metabolic decompensations triggered by infections or surgery . The mean age of diagnosis is approximately 13 years (range 2-24 years) .Hearing loss. Sensorineural hearing loss was reported in 1% and 13% in two large cohorts of individuals with PA .Musculoskeletal system. Severe osteopenia and osteoporosis have been described in adults with PA .Dermatologic manifestations resembling acrodermatitis enteropathica are frequently associated with deficiency of essential amino acids, particularly isoleucine, which can be inadvertently over-restricted in the diet of persons with PA .Other rare complications. Isolated case reports describe clinical findings that could be causally
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. years (range 2-24 years) .Hearing loss. Sensorineural hearing loss was reported in 1% and 13% in two large cohorts of individuals with PA .Musculoskeletal system. Severe osteopenia and osteoporosis have been described in adults with PA .Dermatologic manifestations resembling acrodermatitis enteropathica are frequently associated with deficiency of essential amino acids, particularly isoleucine, which can be inadvertently over-restricted in the diet of persons with PA .Other rare complications. Isolated case reports describe clinical findings that could be causally associated with propionic acidemia, but require further characterization: muscle lipidosis ; myopathy ; premature ovarian insufficiency ; oligomenorrhea ; hypothyroidism ; parathyroid hormone resistance resolving after hemodialysis .Life span. PA confers a high risk of mortality. Reported mortality rates appear to be on the decline: 41%-90% in the 1980-90s, 17%-72% in 2000s, and 7%-12% in early 2010s . Observed decline in reported mortality likely reflects
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. findings that could be causally associated with propionic acidemia, but require further characterization: muscle lipidosis ; myopathy ; premature ovarian insufficiency ; oligomenorrhea ; hypothyroidism ; parathyroid hormone resistance resolving after hemodialysis .Life span. PA confers a high risk of mortality. Reported mortality rates appear to be on the decline: 41%-90% in the 1980-90s, 17%-72% in 2000s, and 7%-12% in early 2010s . Observed decline in reported mortality likely reflects the length of follow up, introduction of newborn screening, expansion of the PA phenotype, proactive medical management, and elective liver transplantation.Long-term adult outcomes. Systematic studies of adult individuals with PA are lacking. Early reports suggest that adults with PA can experience significant osteopenia, osteoporosis, renal failure, and premature ovarian failure .Atypical presentation. Apparently asymptomatic individuals with PA (9%-17% in different cohorts) represent a heterogeneous group consisting of otherwise healthy infants identified after newborn
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. decline in reported mortality likely reflects the length of follow up, introduction of newborn screening, expansion of the PA phenotype, proactive medical management, and elective liver transplantation.Long-term adult outcomes. Systematic studies of adult individuals with PA are lacking. Early reports suggest that adults with PA can experience significant osteopenia, osteoporosis, renal failure, and premature ovarian failure .Atypical presentation. Apparently asymptomatic individuals with PA (9%-17% in different cohorts) represent a heterogeneous group consisting of otherwise healthy infants identified after newborn screening, sibs ascertained through evaluation prompted by diagnosis of the proband, and individuals with a diagnosis of PA with incomplete clinical characterization .Genotype-Phenotype CorrelationsAlthough precise genotype-phenotype correlations do not exist, some general comments related to molecular genetics are relevant.Null variants (PCCA: p.Arg313Ter, p.Ser562Ter; PCCB: p.Gly406fs, p.Gly94Ter, and out-of-frame small
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. otherwise healthy infants identified after newborn screening, sibs ascertained through evaluation prompted by diagnosis of the proband, and individuals with a diagnosis of PA with incomplete clinical characterization .Genotype-Phenotype CorrelationsAlthough precise genotype-phenotype correlations do not exist, some general comments related to molecular genetics are relevant.Null variants (PCCA: p.Arg313Ter, p.Ser562Ter; PCCB: p.Gly406fs, p.Gly94Ter, and out-of-frame small deletions/insertions, genomic abnormalities) result in loss-of-function alleles and are associated with a more severe form of PA .Homozygous missense pathogenic variants, in which partial enzymatic activity is retained (PCCA: p.Ala138Thr, p.Ile164Thr, p.Arg288Gly; PCCB: p.Asn536Asp) have been associated with a less severe phenotype.Some missense pathogenic variants (PCCB p.Gly112A
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. out-of-frame small deletions/insertions, genomic abnormalities) result in loss-of-function alleles and are associated with a more severe form of PA .Homozygous missense pathogenic variants, in which partial enzymatic activity is retained (PCCA: p.Ala138Thr, p.Ile164Thr, p.Arg288Gly; PCCB: p.Asn536Asp) have been associated with a less severe phenotype.Some missense pathogenic variants (PCCB p.Gly112Asp, p.Arg512Cys, and p.Leu519Pro) which affect heterododecamer formation can result in undetectable PCC enzyme activity and severe phenotype .A homozygous PCCB variant in Amish and Mennonite populations, p.Asn536Asp, is associated with high residual PCC activity. It confers a lower risk of developing metabolic crisis, but can lead to late-onset cardiomyopathy.A homozygous PCCB variant, p.Tyr43
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. B p.Gly112Asp, p.Arg512Cys, and p.Leu519Pro) which affect heterododecamer formation can result in undetectable PCC enzyme activity and severe phenotype .A homozygous PCCB variant in Amish and Mennonite populations, p.Asn536Asp, is associated with high residual PCC activity. It confers a lower risk of developing metabolic crisis, but can lead to late-onset cardiomyopathy.A homozygous PCCB variant, p.Tyr435Cys, has been detected in apparently asymptomatic or mildly affected children identified through newborn screening in Japan .NomenclaturePropionic acidemia and propionyl-CoA carboxylase deficiency are the two most common terms used to describe the condition. Ketotic hyperglycinemia was used in the 1960s before defects in propionyl-CoA carboxylase were determined to be the underlying cause of PA . The term propionic aciduria is used infrequently.PrevalenceWorldwide, the incidence of PA varies widely.
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. variant, p.Tyr435Cys, has been detected in apparently asymptomatic or mildly affected children identified through newborn screening in Japan .NomenclaturePropionic acidemia and propionyl-CoA carboxylase deficiency are the two most common terms used to describe the condition. Ketotic hyperglycinemia was used in the 1960s before defects in propionyl-CoA carboxylase were determined to be the underlying cause of PA . The term propionic aciduria is used infrequently.PrevalenceWorldwide, the incidence of PA varies widely. The estimated live-birth incidence of PA is 1:105,000-1:130,000 in the US , 1:166,000 in Italy and 1:250,000 in Germany .The incidence appears to be higher in the Middle East. In the United Arab Emirates, the birth incidence of PA is ~1:20,000-1:45,000 . In Saudi Arabia the birth incidence is 1:28,000 , and can be
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. incidence of PA varies widely. The estimated live-birth incidence of PA is 1:105,000-1:130,000 in the US , 1:166,000 in Italy and 1:250,000 in Germany .The incidence appears to be higher in the Middle East. In the United Arab Emirates, the birth incidence of PA is ~1:20,000-1:45,000 . In Saudi Arabia the birth incidence is 1:28,000 , and can be higher in some Saudi tribes: 1:2000-1:5000 .In Japan, the live birth incidence of severe propionic acidemia is 1:465,000, but increases to 1:17,400 when combined with an apparently asymptomatic form of PA identified through newborn screening .The highest reported birth incidence is found among the Greenlandic Inuits: 1:1000 .Differential DiagnosisElevated C3 (propionylcarnitine) on newborn screening can be caused
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. ,000 , and can be higher in some Saudi tribes: 1:2000-1:5000 .In Japan, the live birth incidence of severe propionic acidemia is 1:465,000, but increases to 1:17,400 when combined with an apparently asymptomatic form of PA identified through newborn screening .The highest reported birth incidence is found among the Greenlandic Inuits: 1:1000 .Differential DiagnosisElevated C3 (propionylcarnitine) on newborn screening can be caused by methylmalonic acidemias resulting from methylmalonyl-CoA mutase deficiency, disorders of intracellular cobalamin metabolism and maternal B12 deficiency.The presence of elevated 3-hydroxypropionic with or without methylcitric acid on the urine organic acid assay should prompt additional diagnostic considerations:Multiple carboxylase deficiency (biotinidase and holocarboxylase synthetase deficiencies), which also shows elevation of lactic acid, 3-hydroxyvaleric acid and 3-methylcrotonylglycine caused
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. on newborn screening can be caused by methylmalonic acidemias resulting from methylmalonyl-CoA mutase deficiency, disorders of intracellular cobalamin metabolism and maternal B12 deficiency.The presence of elevated 3-hydroxypropionic with or without methylcitric acid on the urine organic acid assay should prompt additional diagnostic considerations:Multiple carboxylase deficiency (biotinidase and holocarboxylase synthetase deficiencies), which also shows elevation of lactic acid, 3-hydroxyvaleric acid and 3-methylcrotonylglycine caused by defective activity of pyruvate carboxylase, propionyl-CoA carboxylase, and 3-methylcrotonyl-CoA carboxylaseMethylmalonic acidemias, which have elevations of 2-methylcitric acid and 3-hydroxypropionic acid, and additionally show elevations of methylmalonic acid. Cobalamin C, D, and F metabolism defects result in abnormal homocysteine metabolism. Total plasma homocysteine can help in the diagnostic workup of individuals ascertained with elevated propionylcarnitine.Maternal B12
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. methylcrotonylglycine caused by defective activity of pyruvate carboxylase, propionyl-CoA carboxylase, and 3-methylcrotonyl-CoA carboxylaseMethylmalonic acidemias, which have elevations of 2-methylcitric acid and 3-hydroxypropionic acid, and additionally show elevations of methylmalonic acid. Cobalamin C, D, and F metabolism defects result in abnormal homocysteine metabolism. Total plasma homocysteine can help in the diagnostic workup of individuals ascertained with elevated propionylcarnitine.Maternal B12 deficiency identified through elevated propionylcarnitine on the newborn screen can also present with elevated urinary methylmalonic acid and total plasma homocysteine in infant. In maternal vitamin B12 deficiency, infant vitamin B12 levels can be in the normal range .Urine organic acid assay in individuals with carbonic anhydrase VA deficiency can reveal elevated 3-hydroxypropionic acid, propionylglycine, and methylcitric acid as well as 3-methylcrotonylglycine, 3-hydroxybutyric, alpha-
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. ionylcarnitine.Maternal B12 deficiency identified through elevated propionylcarnitine on the newborn screen can also present with elevated urinary methylmalonic acid and total plasma homocysteine in infant. In maternal vitamin B12 deficiency, infant vitamin B12 levels can be in the normal range .Urine organic acid assay in individuals with carbonic anhydrase VA deficiency can reveal elevated 3-hydroxypropionic acid, propionylglycine, and methylcitric acid as well as 3-methylcrotonylglycine, 3-hydroxybutyric, alpha-ketoglutaric, and 3-hydroxyisovaleric acids. Plasma acylcarnitine profile in individuals with carbonic anhydrase VA deficiency is usually normal.Methylmalonic semialdehyde dehydrogenase deficiency may result in accumulation of 3-hydroxyisobutyric, 3-hydroxypropionic, 3-aminoisobutyric, and methylmalonic acids .Bacterial overgrowth (including Propionibacterium or Lactobacterium) or short gut syndrome Mitochondrial disorder may enter the differential diagnosis when individuals present
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. -hydroxybutyric, alpha-ketoglutaric, and 3-hydroxyisovaleric acids. Plasma acylcarnitine profile in individuals with carbonic anhydrase VA deficiency is usually normal.Methylmalonic semialdehyde dehydrogenase deficiency may result in accumulation of 3-hydroxyisobutyric, 3-hydroxypropionic, 3-aminoisobutyric, and methylmalonic acids .Bacterial overgrowth (including Propionibacterium or Lactobacterium) or short gut syndrome Mitochondrial disorder may enter the differential diagnosis when individuals present with hyperammonemia, metabolic acidosis, ketonuria, and hypoglycemia .Hyperglycinemia can be seen in a wide range of clinical conditions including nonketotic hyperglycinemia, valproate treatment, ketotic hyperglycinemia, and transient glycine encephalopathy. See Glycine Encephalopathy.Hyperammonemia in neonatal PA can prompt clinicians to consider other disorders affecting ammonia metabolism including urea cycle disorders, organic acidemias, pyruvate carboxylase deficiency, carbonic anhydrase VA deficiency, and porto-systemic
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. the differential diagnosis when individuals present with hyperammonemia, metabolic acidosis, ketonuria, and hypoglycemia .Hyperglycinemia can be seen in a wide range of clinical conditions including nonketotic hyperglycinemia, valproate treatment, ketotic hyperglycinemia, and transient glycine encephalopathy. See Glycine Encephalopathy.Hyperammonemia in neonatal PA can prompt clinicians to consider other disorders affecting ammonia metabolism including urea cycle disorders, organic acidemias, pyruvate carboxylase deficiency, carbonic anhydrase VA deficiency, and porto-systemic shunts. Usually, the glutamine levels in hyperammonemic patients with PA are normal or low .Increased anion-gap metabolic acidosis. Possible causes are numerous and may include the following:Those conditions included in the commonly used mnemonic MUDPILES: methanol, uremia (chronic renal failure), diabetic ketoacidosis, propylene glycol, infection, iron, isoniazid, lactic acidosis, ethylene glycol, salicylatesOrganic acidemiasPoisoning and child abuse. In
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. , and porto-systemic shunts. Usually, the glutamine levels in hyperammonemic patients with PA are normal or low .Increased anion-gap metabolic acidosis. Possible causes are numerous and may include the following:Those conditions included in the commonly used mnemonic MUDPILES: methanol, uremia (chronic renal failure), diabetic ketoacidosis, propylene glycol, infection, iron, isoniazid, lactic acidosis, ethylene glycol, salicylatesOrganic acidemiasPoisoning and child abuse. In at least one individual with organic acidemia, propionic acid was misidentified as ethylene glycol . In another case, ethylene glycol poisoning presented with hyperglycinemia and glycolic acid in urine .ManagementThe optimal management of patients with propionic acidemia (PA) is best achieved by a team comprising a physician with metabolic expertise, a dietician, and a genetic counselor. Several proposed acute and chronic management guidelines have become available in recent years . Management of symptomatic hyperammonemic
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. ing and child abuse. In at least one individual with organic acidemia, propionic acid was misidentified as ethylene glycol . In another case, ethylene glycol poisoning presented with hyperglycinemia and glycolic acid in urine .ManagementThe optimal management of patients with propionic acidemia (PA) is best achieved by a team comprising a physician with metabolic expertise, a dietician, and a genetic counselor. Several proposed acute and chronic management guidelines have become available in recent years . Management of symptomatic hyperammonemic patients awaiting confirmatory testing can be particularly challenging and requires pursuit of several diagnostic considerations . Also see Baumgartner et al : Table 6.Evaluations Following Initial DiagnosisTo establish the extent of disease and needs of an individual diagnosed with PA the following evaluations are recommended (see Figure 2) if they have not already been completed:Blood gas with base balance, electrolytes with anion gap, glucose, plasma ammonia, calcium, phosphorus, urine ketonesPlasma amino acids, total
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. Management of symptomatic hyperammonemic patients awaiting confirmatory testing can be particularly challenging and requires pursuit of several diagnostic considerations . Also see Baumgartner et al : Table 6.Evaluations Following Initial DiagnosisTo establish the extent of disease and needs of an individual diagnosed with PA the following evaluations are recommended (see Figure 2) if they have not already been completed:Blood gas with base balance, electrolytes with anion gap, glucose, plasma ammonia, calcium, phosphorus, urine ketonesPlasma amino acids, total and free carnitine and acylcarnitine profile, and urine organic acid analysisComplete blood count to evaluate for cytopeniasConsider initiating an evaluation for sepsis if the CBC and individual’s clinical signs suggest that infection is likelyAmylase and lipase to evaluate for pancreatitisConsultation with a clinical geneticist and/or genetic counselorOnce the patient becomes stable, evaluations include the following:Clinical assessment of growth parameters, ability to feed, the
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. Plasma amino acids, total and free carnitine and acylcarnitine profile, and urine organic acid analysisComplete blood count to evaluate for cytopeniasConsider initiating an evaluation for sepsis if the CBC and individual’s clinical signs suggest that infection is likelyAmylase and lipase to evaluate for pancreatitisConsultation with a clinical geneticist and/or genetic counselorOnce the patient becomes stable, evaluations include the following:Clinical assessment of growth parameters, ability to feed, the need for G-tube placement, and neurologic status.Laboratory assessment of nutritional status (calcium, phosphorus, albumin, prealbumin, plasma amino acids, vitamin levels , iron panel, and minerals and renal function); complete blood count to monitor for cytopeniasClinical evaluation for cardiomyopathy and arrhythmia with ECG, 24-hour Holter monitor, echocardiogramEEG and brain MRI in symptomatic individualsDevelopmental evaluationDilated eye examinationHearing evaluationImmunology consultOtherComplet
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. , ability to feed, the need for G-tube placement, and neurologic status.Laboratory assessment of nutritional status (calcium, phosphorus, albumin, prealbumin, plasma amino acids, vitamin levels , iron panel, and minerals and renal function); complete blood count to monitor for cytopeniasClinical evaluation for cardiomyopathy and arrhythmia with ECG, 24-hour Holter monitor, echocardiogramEEG and brain MRI in symptomatic individualsDevelopmental evaluationDilated eye examinationHearing evaluationImmunology consultOtherComplete adherence to regional immunization schedules and influenza vaccination is indicated .Maintain a high index of suspicion for endocrine, immune, and renal problems and address accordingly.Treatment of ManifestationsNeonatal/acute decompensation. Birth, infections, trauma, surgery, postpartum recovery, or other forms of stress and hormonal changes can result in a catabolic response that leads, among other things, to protein breakdown with release of propiogenic amino acids that cannot be metabolized in PA. The goal of
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. Immunology consultOtherComplete adherence to regional immunization schedules and influenza vaccination is indicated .Maintain a high index of suspicion for endocrine, immune, and renal problems and address accordingly.Treatment of ManifestationsNeonatal/acute decompensation. Birth, infections, trauma, surgery, postpartum recovery, or other forms of stress and hormonal changes can result in a catabolic response that leads, among other things, to protein breakdown with release of propiogenic amino acids that cannot be metabolized in PA. The goal of acute management is to reverse this process through promotion of anabolism and removal of toxic intermediates. The treatment of individuals with acutely decompensated PA is a medical emergency and requires a transfer to a center with biochemical genetics expertise and the ability to support urgent hemodialysis, especially if hyperammonemia is present.In-patient managementAssess and manage ventilation and circulation as necessary.Treat precipitating factors (fever, infection, dehydration, pain, vomiting, and other sources of stress).
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. in PA. The goal of acute management is to reverse this process through promotion of anabolism and removal of toxic intermediates. The treatment of individuals with acutely decompensated PA is a medical emergency and requires a transfer to a center with biochemical genetics expertise and the ability to support urgent hemodialysis, especially if hyperammonemia is present.In-patient managementAssess and manage ventilation and circulation as necessary.Treat precipitating factors (fever, infection, dehydration, pain, vomiting, and other sources of stress).Determine the need for sepsis workup and antibiotics.Reverse catabolism by giving intravenous glucose and lipids.The volume, glucose content and electrolyte composition of intravenous fluids is determined by age, target glucose infusion rate, cardiovascular status, renal condition, and co-administration of other medications.Intravenous D10 ½ normal saline typically between 100% and 150% of the maintenance requirements is a common starting fluid. Dextrose solutions exceeding the concentration of 12.5% require a central line placement. The target
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. other sources of stress).Determine the need for sepsis workup and antibiotics.Reverse catabolism by giving intravenous glucose and lipids.The volume, glucose content and electrolyte composition of intravenous fluids is determined by age, target glucose infusion rate, cardiovascular status, renal condition, and co-administration of other medications.Intravenous D10 ½ normal saline typically between 100% and 150% of the maintenance requirements is a common starting fluid. Dextrose solutions exceeding the concentration of 12.5% require a central line placement. The target glucose infusion rates varies by age .Additional calories can be provided using parenteral lipid emulsion.The use of intravenous insulin drip may be needed to maintain euglycemia and promote anabolism.Manage protein intake to reduce propiogenic precursors; avoidance of protein transiently for <24-36 hours may be required.Transition to enteral feedings should be commenced as soon as they are tolerated (see Prevention of Primary Manifestations, Dietary management).If transition to enteral feeding
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. central line placement. The target glucose infusion rates varies by age .Additional calories can be provided using parenteral lipid emulsion.The use of intravenous insulin drip may be needed to maintain euglycemia and promote anabolism.Manage protein intake to reduce propiogenic precursors; avoidance of protein transiently for <24-36 hours may be required.Transition to enteral feedings should be commenced as soon as they are tolerated (see Prevention of Primary Manifestations, Dietary management).If transition to enteral feedings within 48 hours is not possible, total parenteral nutrition is required.Parenteral amino acid solutions are prescribed based on the recommended daily intake of age-appropriate energy, protein, isoleucine, valine, methionine, and threonine and adjusted using the daily and weekly growth data and plasma amino acid concentrations.Remove toxic compounds.Pharmacologic detoxification:Nitrogen scavenger medications (sodium benzoate, sodium phenylacetate, sodium phenylbutyrate), such as those used in urea cycle disorders to help control ammonia levels
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. .If transition to enteral feedings within 48 hours is not possible, total parenteral nutrition is required.Parenteral amino acid solutions are prescribed based on the recommended daily intake of age-appropriate energy, protein, isoleucine, valine, methionine, and threonine and adjusted using the daily and weekly growth data and plasma amino acid concentrations.Remove toxic compounds.Pharmacologic detoxification:Nitrogen scavenger medications (sodium benzoate, sodium phenylacetate, sodium phenylbutyrate), such as those used in urea cycle disorders to help control ammonia levels during acute decompensations, should be used with caution in the treatment of hyperammonemia associated with PA as they can accentuate frequently observed low plasma glutamine . For a discussion regarding the use of sodium benzoate versus sodium phenylacetate and sodium phenylbutyrate in propionic acidemia see Baumgartner et al .Oral N-carbamoylglutamate (carglumic acid; 100 mg/kg divided every 6 hours in individuals <20 kg and 2.
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gene_reviews
https://www.ncbi.nlm.nih.gov/books/NBK92946/
QE2k7oK
Propionic Acidemia
C0268579
31,762
propionic acidemia. disorders to help control ammonia levels during acute decompensations, should be used with caution in the treatment of hyperammonemia associated with PA as they can accentuate frequently observed low plasma glutamine . For a discussion regarding the use of sodium benzoate versus sodium phenylacetate and sodium phenylbutyrate in propionic acidemia see Baumgartner et al .Oral N-carbamoylglutamate (carglumic acid; 100 mg/kg divided every 6 hours in individuals <20 kg and 2.2 gm/m2 in individuals >20 kg) can aid in the detoxification of ammonia during neonatal and acute decompensations .Extracorporeal detoxification is required for persistent acidosis and hyperammonemia (plasma ammonia level >250-300 μmol/L) not responding to fluid and drug treatment. Methods include (depending on age and clinical situation) continuous veno-venous hemofiltration, extracorporeal membrane oxygenation, or hemodialysis .Carnitine supplementation (100 mg/kg/day
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