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==Presentation==
==Presentation==
PDHA causes [[Lactic acidosis]]; large amounts of [[lactic acid]] in the blood but with a normal [[pyruvate]]/[[lactate]] ratio. Symptoms are varied, and include developmental defects (especially of the brain and nervous system), muscular [[spasticity]] and early death.
PDHA causes [[Lactic acidosis]]; large amounts of [[lactic acid]] in the blood but with a normal [[pyruvate]]/[[lactate]] ratio. Symptoms are varied, and include developmental defects (especially of the brain and nervous system), muscular [[spasticity]] and early death.
==Differential diagnosis==
Pyruvate dehydrogenase deficiency must be differentiated from other diseases that cause neurological manifestations in infants.
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |Diseases
! colspan="4" |Type of motor abnormality
! rowspan="2" |Clinical findings
! rowspan="2" |Laboratory findings and diagnostic tests
! rowspan="2" |Radiographic findings
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Spasticity
!Hypotonia
!Ataxia
!Dystonia
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Leigh syndrome]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
* Progressive [[psychomotor]] regression
* [[Seizures]]
* External [[ophthalmoplegia]]
* [[Lactic acidosis]]
* [[Vomiting]]
| style="background: #F5F5F5; padding: 5px;" |
* Increased [[lactate]] levels in [[blood]] and [[CSF]]
* Genetic testing 
| style="background: #F5F5F5; padding: 5px;" |
* MRI: abnormal [[white matter]] signal in the [[putamen]], [[basal ganglia]], and [[brainstem]] on T2 images
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Niemann-Pick]] disease type C
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
* Progressive [[neurodegeneration]]
* [[Hepatosplenomegaly]]
* Systemic involvement of [[liver]], [[spleen]], or [[lung]] preceedes [[neurologic]] symptoms
| style="background: #F5F5F5; padding: 5px;" |
* Abnormal [[liver]] function tests
* [[Fibroblast]] cell culture with filipin staining
| style="background: #F5F5F5; padding: 5px;" |
* MRI:
**[[Cerebral]] and [[cerebellar]] [[atrophy]]
**Thinning of the [[corpus callosum]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Infantile Refsum disease
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* Abnormalities of the [[optic nerve]] and disc
* [[Retinitis pigmentosa]]
* [[Sensorineural]] hearing loss
* [[Hepatomegaly]] and [[cirrhosis]]
* [[Neurologic]] deterioration is slower than in [[Zellweger syndrome]] or ALD
| style="background: #F5F5F5; padding: 5px;" |Elevated plasma VLCFA levels
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Adrenoleukodystrophy]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* [[Cognitive]] and behavioral abnormalities
* [[Adrenal insufficiency]]
* [[Hyperpigmented]] skin
* [[Gonadal dysfunction]]
* [[Neurologic]] deterioration progresses at a variable rate
| style="background: #F5F5F5; padding: 5px;" |
* Elevated plasma VLCFA levels
* Molecular [[genetic testing]] for mutations in the ABCD1 gene
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Zellweger syndrome]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* [[Craniofacial]] dysmorphism
* [[Hepatomegaly]]
* Neonatal [[seizures]]
* Profound developmental delay
* [[MRI]] findings include [[cortical]] and [[white matter]] abnormalities
* [[Neurologic deterioration]] is rapid and infants rarely survive beyond six months of age
| style="background: #F5F5F5; padding: 5px;" |
* Elevated plasma VLCFA levels
* Elevated levels of [[phytanic acid]], pristanic acid, and pipecolic acid in plasma and [[fibroblasts]]
* Reduced plasmalogen in [[erythrocytes]]
* Molecular [[genetic]] testing for [[mutations]] in the PEX1 or PEX6 genes
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pyruvate dehydrogenase deficiency]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* [[Lactic acidosis]]
* [[Seizures]]
* [[Intellectual disability]]
| style="background: #F5F5F5; padding: 5px;" |
* Elevated [[lactate]] and pyruvate levels in [[blood]] and CSF
* Abnormal PDH enzymatic activity in cultured fibroblasts
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Arginase deficiency]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* [[Hyperammonemia]]
* [[Encephalopathy]]
* [[Respiratory alkalosis]]
| style="background: #F5F5F5; padding: 5px;" |
* Elevated [[ammonia]] level
* Elevated [[arginine]] level
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Holocarboxylase synthetase deficiency
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* [[Ketoacidosis]]
* [[Dermatitis]]
* [[Alopecia]]
* [[Seizures]]
* [[Developmental delay]]
| style="background: #F5F5F5; padding: 5px;" |Elevated levels of:
* Beta-hydroxyisovalerate
* Beta-methylcrotonylglycine
* Beta-hydroxypropionate
* Methylcitrate
* Tiglylglycine
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Glutaric aciduria type 1
| style="background: #F5F5F5; padding: 5px;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
* Episodes of [[metabolic decompensation]] and [[encephalopathy]] often precipitated by [[infection]] and [[fever]]
* Rarely presents in the newborn period
* Microencephalic [[macrocephaly]]
* [[Seizures]] (approximately 20 percent)
* [[Cognitive function]] is preserved
| style="background: #F5F5F5; padding: 5px;" |Elevated levels of:
* [[glutaric acid]]
* 3-hydroxyglutaric acid
| style="background: #F5F5F5; padding: 5px;" |
* MRI:
**[[Frontal]] and [[temporal]] [[atrophy]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Ataxia telangiectasia]]
| style="background: #F5F5F5; padding: 5px;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
* Progressive [[cerebellar]] [[ataxia]]
* Abnormal eye movements
* [[Oculocutaneous]] [[telangiectasias]]
* Immune deficiency
* Increased risk of [[malignancy]]
| style="background: #F5F5F5; padding: 5px;" |
* Elevated serum alpha-fetoprotein level
* Low [[IgA]] and [[IgG]] levels
* [[Lymphopenia]]
* Genetic testing for [[mutation]] in the ATM gene
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pontocerebellar]] [[hypoplasias]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* Progressive muscle [[atrophy]]
* [[Microcephaly]]
* [[Developmental delay]]
| style="background: #F5F5F5; padding: 5px;" |[[Genetic]] testing for PCH gene mutations
| style="background: #F5F5F5; padding: 5px;" |
* MRI :
**Small [[cerebellum]] and [[brainstem]] including the [[pons]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Metachromatic leukodystrophy]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* Regression of motor skills
* [[Seizures]]
* [[Optic atrophy]]
* Reduced or absent [[deep tendon reflexes]]
* [[Intellectual disability]]
| style="background: #F5F5F5; padding: 5px;" |
* Deficient arylsulfatase A enzyme activity in [[leukocytes]] or cultured skin fibroblasts
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pelizaeus-Merzbacher]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* [[Nystagmus]]
* [[Cognitive impairment]]
* Onset in infancy
* Slowly progressive
* Language development may be normal
| style="background: #F5F5F5; padding: 5px;" |
* [[Genetic]] testing for [[mutations]] in PLP1 gene
| style="background: #F5F5F5; padding: 5px;" |
*MRI:
**[[White matter]] abnormalities
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Angelman syndrome]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* Profound [[intellectual disability]]
* Postnatal [[microcephaly]]
* Typical abnormal behaviors (paroxysmal laughter, easily excitable)
| style="background: #F5F5F5; padding: 5px;" |
* Methylation studies and [[chromosome]] microarray to detect chromosome 15 anomalies and UBE3A mutations
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Rett syndrome]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
* Occurs almost exclusively in females
* Normal development during first six months followed by regression and loss of milestones
* Loss of speech capability
* Stereotypic hand movements
* [[Seizures]]
* [[Autistic]] features
| style="background: #F5F5F5; padding: 5px;" |
* Clinical diagnosis
* [[Genetic]] testing for MECP2 mutations
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Lesch-Nyhan syndrome]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
* [[Self-mutilating]] behavior
* [[Urinary]] stones due to [[hyperuricemia]]
| style="background: #F5F5F5; padding: 5px;" |
* Elevated [[uric acid]] level
* Abnormal enzymatic activity of HPRT in cultured fibroblasts
* [[Genetic]] testing for HPRT gene [[mutations]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Miller-Dieker lissencephaly
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |
* [[Lissencephaly]]
* [[Microcephaly]]
* [[Dysmorphic]] features
* [[Seizures]]
* Failure to thrive
| style="background: #F5F5F5; padding: 5px;" |
* Cytogenetic testing for 17p13.3 microdeletion
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Dopa-responsive [[dystonia]]
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" |
* Onset in early childhood
* Symptoms worsen with [[fatigue]] and exercise
| style="background: #F5F5F5; padding: 5px;" |
* Positive response to a trial of [[levodopa]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |--
|}


==Genetics==
==Genetics==
Line 41: Line 341:
{{Mitochondrial diseases}}
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{{Metabolic pathology}}
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Latest revision as of 15:56, 9 October 2017

Pyruvate dehydrogenase deficiency
ICD-10 E74.4
OMIM 312170
DiseasesDB 30060
eMedicine ped/1969 
MeSH D015325

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Please Take Over This Page and Apply to be Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [2] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.

Overview

Pyruvate Dehydrogenase Deficiency (PDHA) is a human genetic disease. It follows a sex-linked, dominant inheritance pattern, but is approximately equally prevalent in both males and females. It affects a gene which codes for a critical enzyme complex, the Pyruvate dehydrogenase complex (PDC) which links the metabolic pathways of glycolysis and the citric acid cycle by transforming pyruvate into Acetyl CoA

The pyruvate dehydrogenase complex facilitates oxidative decarboxylation, the chemical reaction between glycolysis and the citric acid cycle.

Presentation

PDHA causes Lactic acidosis; large amounts of lactic acid in the blood but with a normal pyruvate/lactate ratio. Symptoms are varied, and include developmental defects (especially of the brain and nervous system), muscular spasticity and early death.

Differential diagnosis

Pyruvate dehydrogenase deficiency must be differentiated from other diseases that cause neurological manifestations in infants.

Diseases Type of motor abnormality Clinical findings Laboratory findings and diagnostic tests Radiographic findings
Spasticity Hypotonia Ataxia Dystonia
Leigh syndrome - - + +
Niemann-Pick disease type C - - + +
  • Abnormal liver function tests
  • Fibroblast cell culture with filipin staining
Infantile Refsum disease - + + - Elevated plasma VLCFA levels --
Adrenoleukodystrophy + - - -
  • Elevated plasma VLCFA levels
  • Molecular genetic testing for mutations in the ABCD1 gene
--
Zellweger syndrome - + - - --
Pyruvate dehydrogenase deficiency + + + -
  • Elevated lactate and pyruvate levels in blood and CSF
  • Abnormal PDH enzymatic activity in cultured fibroblasts
--
Arginase deficiency + - - - --
Holocarboxylase synthetase deficiency - + - - Elevated levels of:
  • Beta-hydroxyisovalerate
  • Beta-methylcrotonylglycine
  • Beta-hydroxypropionate
  • Methylcitrate
  • Tiglylglycine
--
Glutaric aciduria type 1 - - - + Elevated levels of:
Ataxia telangiectasia - - + - --
Pontocerebellar hypoplasias - + - - Genetic testing for PCH gene mutations
Metachromatic leukodystrophy - + + -
  • Deficient arylsulfatase A enzyme activity in leukocytes or cultured skin fibroblasts
--
Pelizaeus-Merzbacher + - + -
Angelman syndrome - - + -
  • Methylation studies and chromosome microarray to detect chromosome 15 anomalies and UBE3A mutations
--
Rett syndrome + - - +
  • Occurs almost exclusively in females
  • Normal development during first six months followed by regression and loss of milestones
  • Loss of speech capability
  • Stereotypic hand movements
  • Seizures
  • Autistic features
  • Clinical diagnosis
  • Genetic testing for MECP2 mutations
--
Lesch-Nyhan syndrome + - - + --
Miller-Dieker lissencephaly + + - -
  • Cytogenetic testing for 17p13.3 microdeletion
--
Dopa-responsive dystonia + - - +
  • Onset in early childhood
  • Symptoms worsen with fatigue and exercise
  • Positive response to a trial of levodopa
--


Genetics

PDHA is most commonly linked to the alpha unit of E1, but recessive variants exist.

Treatment

Use of a ketogenic diet has been described.[1]

Current research is being conducted on the viability of Dichloroacetic acid to treat the lactic acidosis commonly accompanied by this disorder.[2][3] Additionally, there is research being conducted on the viability of gene therapy for sufferers of this condition as well as many other mitochondrial defects.

References

  1. Barañano KW, Hartman AL (2008). "The ketogenic diet: uses in epilepsy and other neurologic illnesses" ([dead link]). Curr Treat Options Neurol. 10 (6): 410–9. doi:10.1007/s11940-008-0043-8. PMC 2898565. PMID 18990309. Unknown parameter |month= ignored (help)
  2. Berendzen K, Theriaque DW, Shuster J, Stacpoole PW (2006). "Therapeutic potential of dichloroacetate for pyruvate dehydrogenase complex deficiency". Mitochondrion. 6 (3): 126–35. doi:10.1016/j.mito.2006.04.001. PMID 16725381. Unknown parameter |month= ignored (help)
  3. Stacpoole PW, Kurtz TL, Han Z, Langaee T (2008). "Role of dichloroacetate in the treatment of genetic mitochondrial diseases". Adv. Drug Deliv. Rev. 60 (13–14): 1478–87. doi:10.1016/j.addr.2008.02.014. PMID 18647626.


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