Maple syrup urine disease 2011

Summary

The maple syrup urine (MSUD) disease is an autosomal recessive disorder which is caused by a disturbance in the amino acid metabolism. The symptomes of MSUD are mental and physical retardation, feeding problems, vomiting, dehydration, lethargy, hypotonia, seizures, hypoglycaemia, ketoacidosis, opisthotonus, pancreatitis, coma and neurological decline. If the disease remains unrecognized it can also lead to brain damage and in the last resort to death. The most characteristical symptome is the sweet smell of the urine, just like maple syrup.

Phenotype

The MSUD occurs because of a defect in the branched-chain alpha-keto acid dehydrogenase complex (BCKDC). This defect leads to a block in oxidative decarboxylation which results in a rising concentration of branched-chain amino acids (BCAA) and their toxic by-products in blood and urine. The MSUD can be divided in 5 subtypes:

- Classic Severe MSUD

 The classic form of MSUD is the worst one of this disease. The level of  the BCAAs are dramatically high in blood, urine and cerebrospinal
 fluid and the BCKD activity is less than 2% of normal.
 The children seams normal at birth but after 4 to 7 days after birth the first symptoms like lethargy and little interest in feeding appear. 
 With progress of the disease it comes to weight loss and progressive neurological deterioration and hypo- to hypertonia. If the disease is  
 not treated it leads to coma and death within several months after birth .

- Intermediate MSUD

 In the intermediate MSUD the level of BCAAS in blood and urine rises permanent and the neurological impairment becomes worse. The level of 
 BCKD ranges from 3% to 30% of normal. In many cases the acute metabolic decompensation do not occur.

- Intermittent MSUD

 Patients with the intermittent MSUD develop normal. In normal life situations these people have no symptoms and also a normal level of  
 BCAAS. But in stress situations acute metabolic decompensations arise. The level of activity of BCKD ranges from 5% to 50% of normal. 
 Symptoms can appear between 5 months to 2 years of age when the patients have an infection.

- Thiamine-responsive MSUD

 The progress of the thiamine-responsive MSUD is quite similar to the one of the intermediate MSUD. There is about 5 times more BCAA in the 
 plasma than normal and it is characteristically that alloisoleucine can be detected.
 This subtype can be handled by a low protein diet which results in a normal BCAA level.

- E3-Deficient MSUD with Lactic Acidosis

 This subtype of MSUD causes from a defect in the E3 component of the BCKD complex.  It is a very form with only 20 reported cases and in  
 the first few month the patient develope quite normal. The symptomes are nearly the same of intermediate MSUD but these patients suffer also 
 lactic acidosis.

Cross-references

See also description of this disease in

• Wikipedia
• OMIM
• Genetics Home Reference
• MedlinePlus
• Medscape
• NCBI
• NORD
• PubMed
• Medical Biochemistry Page

Biochemical disease mechanism

MSUD is caused by mutations in the Branched-Chain alpha-keto acid dehydrogenase complex (BCKD). This complex is essential for the break down of branched-chain amino acids (Leucine, Isoleucine and Valine). Leucine, Isoleucine and Valine are part of protein-rich food, such as eggs, milk and meat. Mutations in the BCKD-complex prevent the breakdown of the amino acids, which then accumulate, together with their toxic by-products, in the body.

File:MSUDaminoacids

Degradation of Leucine, Isoleucin and Valine(source: NCBI)

Degradation of Leucine, Isoleucin and Valine (source: KEGG)

The BCKD complex consists of four proteins:

• BCKDHA (Branched-CHain Keto Acid Dehydrogenase, alpha-subunit)
• BCKDHB (Branched-CHain Keto Acid Dehydrogenase, beta-subunit)
• DBT (Dihydrolipoamide Branched-Chain Transacylase)
• DLD (Dihydrolipoamide Dehydrogenase)

Mutations in each of these genes lead to MSUD.

Cross-references

• link to KEGG: [1]
• link to MetaCyc: [2]

Mutations

There are currently listed 39 mutations in the BCKDHA protein.(source: HGMD)

Reference sequence

Which sequence does not cause the disease and is most often found in the population. Reference Sequence of BCKDHA

Neutral mutations

• BCKDHA_neutral_mutations.

Disease causing mutations

• Q80E