Adrenoleukodystrophy. Failure of immunosuppression to prevent neurological progression.

Severe immunosuppression with prednisone and cyclophosphamide failed to prevent neurological progression in a patient with adrenoleukodystrophy.

Urea cycle regulation: I. Coupling of ornithine metabolism to mitochondrial oxidative phosphorylation.

Ornithine metabolism is coupled to oxidative phosphorylation in isolated rat liver mitochondria. The pathway involving ornithine: alpha-ketoglutarate transaminase (OKT), glutamic semialdehyde dehydrogenase (GSDH), and glutamate dehydrogenase (GDH) with cycling of alpha-ketoglutarate-glutamate at the OKT reaction appears to be involved. Ornithine may be utilized by this pathway to sustain ATP levels during mitochondrial energy-deficiency states with resultant decreased urea-cycle flux and increased ammonia production. This pathophysiologic mechanism suggests that hyperammonemia is a consequence of an energy-deficiency state. Therapy directed toward alleviating the energy-deficiency state may be more beneficial than efforts to reduce ammonia levels.

The metabolic consequences of experimental intraventricular hemorrhage.

Experimental intraventricular hemorrhage was produced by injection of autologous fresh blood (0.25 ml/kg) or artificial CSF into the right lateral ventricle of 24 dogs. A transient ventricular fluid acidosis (pH drop to 7.09) was accompanied by increased lactate, pyruvate, ammonia, and Pco2, and decreased bicarbonate and glucose. High lactate/pyruvate ratios were the most persistent abnormality. The control group, which received intraventricular artificial CSF, developed minimal ventricular fluid acidosis (pH 7.26). Lumbar CSF and venous blood acid-base parameters did not change. Simultaneous cisternal samples obtained from some of the animals reflected similar metabolic abnormalities of lesser magnitude. Intraventricular injection of sodium bicarbonate normalized the pH in four animals.

Friedreich ataxia. II. Normal kinetics of lipoamide dehydrogenase.

Lipoamide dehydrogenase (LAD) kinetic values, Km and Vmax, were normal in 11 patients with Friedreich ataxia. Fibroblast activities of the pyruvate and alpha-ketoglutarate dehydrogenase complex, and LAD activities, were also normal. There was no reduction in oxidative decarboxylation of pyruvate, alpha-ketoglutarate, or several other substrates in intact fibroblasts. Methodologic differences may account for differences of opinion about putative abnormalities of the alpha-ketoacid dehydrogenase complexes.

Carnitine deficiency, organic acidemias, and Reye's syndrome.

Relative carnitine deficiency is important in the pathophysiology of several disorders, including Reye's syndrome and organic acidemias. In acute clinical crises, carnitine serves as a "buffer," trapping toxic acyl compounds. Mitochondrial failure develops in carnitine deficiency when there is insufficient tissue carnitine available to buffer toxic acyl-CoA metabolites. Toxic levels of acyl-CoA impair the citrate cycle, gluconeogenesis, the urea cycle, and fatty-acid oxidation. Carnitine replacement therapy is safe and induces excretion of toxic acyl groups in the urine.

Inhibitory effects of sodium valproate on oxidative phosphorylation.

Sodium valproate (VP) inhibited oxidative phosphorylation in isolated rat liver mitochondria. State 3 rates of oxygen consumption with glutamate as substrate were 80% of control values at a low VP concentration (24 microM). At 240 microM, there was more than 50% inhibition of glutamate and alpha-ketoglutarate state 3 rates. Succinate state 3 rates were 80% of control values, and uncoupling was noted at 2400 microM VP. These VP effects were similar to those of propionate and isovalerate, suggesting a common mechanism of toxicity. Inhibition of mitochondrial oxidative phosphorylation may explain why VP intoxication causes a hepatocerebral disorder that resembles Reye syndrome.

Friedreich's disease: IV. Reduced mitochondrial malic enzyme activity in heterozygotes.

Friedreich's disease (FD) obligate heterozygotes have reduced mitochondrial malic enzyme (MEm) activity in cultured fibroblasts. This indicates that the MEm deficiency in homozygous affected patients is genetically determined. Heterozygote MEm activity was only 20% of the control mean activity, lower than the 50% expected in an autosomal-recessive disorder. This may result from negative interactions between mutant and normal subunits in the tetrameric enzyme. These data support the idea that MEm deficiency causes FD, but further studies are required to prove this hypothesis.

Effects of octanoate on rat brain and liver mitochondria.

Octanoate increased state 3 and state 4 respiration in rat liver mitochondria. The respiratory control rates decreased because state 4 was disproportionately affected. The ADP:O ratio was not affected. Octanoate produced a fall in the protonmotive force (delta p) of 30 mV during state 3 and state 4. The mitochondrial inner membrane proton conductance (Cm,H+) increased twofold during state 4. Similar effects were observed in polarographic assays of brain mitochondria, but measurements of delta p and Cm,H+ were not possible. Octanoate produces loose coupling in isolated mitochondria. This effect may play a role in the pathogenesis of Reye's syndrome.

Friedreich ataxia: III. Mitochondrial malic enzyme deficiency.

Polarographic assays of oxidative phosphorylation in muscle mitochondria indicated abnormal pyruvate-malate metabolism in Friedreich ataxia (FA). Pursuing this clue, more specific assays were performed. Mitochondrial malic enzyme (MEm; malate: NADP+ oxidoreductase) specific activity was 10% of controls in fibroblasts from eight FA patients (p less than 0.0001). Cytosolic malic enzyme was modestly increased in FA fibroblasts. Mitochondrial and cytosolic malate dehydrogenase and aspartate aminotransferase, and malate transport on the dicarboxylate and alpha-ketoglutarate carriers were normal in fibroblasts or leukocytes. MEm activity is normally highest in the nervous system and heart is important in regulating carbohydrate metabolism. MEm deficiency could cause FA; further studies are required to substantiate this hypothesis.

Friedreich's disease: V. Variant form with vitamin E deficiency and normal fat absorption.

A 30-year-old woman was thought to have Friedreich's disease because of progressive ataxia, dysarthria, and titubation from age 3 years. Her diet was normal, and there were neither symptoms nor laboratory evidence of liver disease or fat malabsorption. Serum vitamin E content and the ratio of serum vitamin E to total serum lipid were very low, but serum vitamin A, cholylglycine, and lipid levels were normal, as was an oral vitamin E tolerance test. Muscle biopsy showed the lysosomal inclusions of vitamin E deficiency. Mitochondria had normal oxidative phosphorylation using polarographic assays. The cause of her vitamin E deficiency was unknown.

Malignant atrophic papulosis (Kohlmeier-Degos disease) in childhood.

Malignant atrophic papulosis (Kohlmeier-Degos disease) is reported for the first time with pathologic verification of central nervous system involvement in a child. The disease began in infancy with rare recurring skin lesions; the child died at the age of 7, after progressive neurologic deterioration. Diagnosis was suspected clinically and confirmed by biopsy of a typical skin lesion. Recognition of this disorder by its dermatologic manifestations may obviate invasive diagnostic procedures.

Brain mitochondrial metabolism in experimental thiamine deficiency.

Thiamine deficiency causes Wernicke's encephalopathy, although the precise mechanism is unknown. We used a low-thiamine diet in conjunction with a thiamine analog, pyrithiamine, as a model of severe thiamine deficiency in rats. We investigated the function of intact, coupled mitochondria isolated from both brain and liver. State 4 respiration did not change in the thiamine-deficient animals. Brain state 3 rates fell in thiamine-deficient animals when pyruvate/malate, alpha-ketoglutarate, or glutamate were used as substrate. Liver state 3 rates were depressed only when pyruvate/malate was substrate. Activities of brain and liver pyruvate dehydrogenase complex and alpha-ketoglutarate dehydrogenase complex were depressed in the thiamine-deficient group. We conclude that the mitochondrial abnormalities resulting from thiamine deficiency are secondary to depression of thiamine-mediated enzyme activity, rather than from a putative role of thiamine in chemiosmotic coupling, and that the resulting abnormalities in ATP synthesis and perhaps in glutamate catabolism result in the irreversible neurologic defect seen in this disease.

Anticonvulsant use during pregnancy.

Although antiepileptic medications may play a role in fetal malformations, this risk appears no greater than the risk associated with either the seizures themselves or a change in medication during pregnancy. In general, the number and the dose of antiepileptic medications should be minimized during pregnancy. Potential complications during the pregnancy must be anticipated. Drug levels must be monitored. Because the fetus is at a somewhat higher risk, ultrasound studies may be useful in monitoring the pregnancy. Delivery should take place in a center where appropriate facilities are available if intervention is required during labor or if the baby is malformed. Both the infant and the mother should be monitored closely after the delivery.

The inherited ataxias.

Diagnosis and classification of the inherited ataxias are reviewed with emphasis on recognizing treatable disorders. Even when basic defects are untreatable, many complications of the degenerative process are amenable to therapy.

Reye syndrome: an international perspective.

An international perspective of Reye syndrome provides insights not noticeable with a parochial perspective. Sources of variation in Reye syndrome include geographic factors. The disappearance of Reye syndrome occurred globally, raising doubts about the importance of regional efforts to eliminate specific putative causes.

The inherited ataxias.

Clinical, biochemical, and genetic studies have brought clarity to many issues concerning the inherited ataxias. The classification, diagnosis, and therapy of hereditary ataxias are now better understood although many questions remain. Basic defects are identified in some disorders.

A microchamber for polarographic assay.

A glass micro-chamber which allows polarographic assay in a volume of 180 microliter is described. The conical shape of this chamber allows efficient mixing with a Teflon magnetic flea. This chamber facilitates the study of the small quantities of mitochondria obtained from human tissue biopsies or animal sources. The polarographic assay of mouse liver mitochondria is described.