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Pyruvate dehydrogenase E3 deficiency(DLDD)

MedGen UID:
1805500
Concept ID:
C5574660
Disease or Syndrome
Synonyms: Dihydrolipoamide Dehydrogenase (E3) Deficiency; DIHYDROLIPOAMIDE DEHYDROGENASE DEFICIENCY; Dihydrolipoamide Dehydrogenase E3 Deficiency; DLD DEFICIENCY; DLDD; E3 DEFICIENCY; Lipoamide dehydrogenase deficiency; Lipoamide dehydrogenase deficiency, lactic acidosis due to; Maple syrup urine disease, type 3; MAPLE SYRUP URINE DISEASE, TYPE III
SNOMED CT: Maple syrup urine disease, type III (29914000); Deficiency of diaphorase (29914000); Cytochrome-b reductase deficiency (29914000); Deficiency of dihydrolipoamide dehydrogenase (29914000); Lactic acidosis due to LAD deficiency (29914000); DLD - Dihydrolipoamide dehydrogenase deficiency (29914000); Deficiency of lipoamide reductase (NADH) (29914000); Diaphorase deficiency (29914000); Dihydrolipoyl dehydrogenase deficiency (29914000); Lipoamide dehydrogenase deficiency (29914000); Dihydrolipoamide dehydrogenase deficiency (29914000); Congenital infantile lactic acidosis due to LAD deficiency (29914000); Maple syrup urine disease with lactic acidosis (29914000)
Modes of inheritance:
Autosomal recessive inheritance
MedGen UID:
141025
Concept ID:
C0441748
Intellectual Product
Source: Orphanet
A mode of inheritance that is observed for traits related to a gene encoded on one of the autosomes (i.e., the human chromosomes 1-22) in which a trait manifests in individuals with two pathogenic alleles, either homozygotes (two copies of the same mutant allele) or compound heterozygotes (whereby each copy of a gene has a distinct mutant allele).
 
Gene (location): DLD (7q31.1)
 
Monarch Initiative: MONDO:0009529
OMIM®: 246900
Orphanet: ORPHA2394

Disease characteristics

Excerpted from the GeneReview: Dihydrolipoamide Dehydrogenase Deficiency
The phenotypes of dihydrolipoamide dehydrogenase (DLD) deficiency are an overlapping continuum that ranges from early-onset neurologic manifestations to adult-onset liver involvement and, rarely, a myopathic presentation. Early-onset DLD deficiency typically manifests in infancy as hypotonia with lactic acidosis. Affected infants frequently do not survive their initial metabolic decompensation, or die within the first few years of life during a recurrent metabolic decompensation. Children who live beyond the first two to three years frequently exhibit growth deficiencies and residual neurologic deficits (intellectual disability, spasticity, ataxia, and seizures). In contrast, isolated liver involvement can present as early as the neonatal period and as late as the third decade. Evidence of liver injury/failure is preceded by nausea and emesis and frequently associated with encephalopathy and/or coagulopathy. Acute metabolic episodes are frequently associated with lactate elevations, hyperammonemia, and hepatomegaly. With resolution of the acute episodes affected individuals frequently return to baseline with no residual neurologic deficit or intellectual disability. Liver failure can result in death, even in those with late-onset disease. Individuals with the myopathic presentation may experience muscle cramps, weakness, and an elevated creatine kinase. [from GeneReviews]
Authors:
Shane C Quinonez  |  Jess G Thoene   view full author information

Additional descriptions

From OMIM
Dihydrolipoamide dehydrogenase deficiency (DLDD) is an autosomal recessive metabolic disorder characterized biochemically by a combined deficiency of the branched-chain alpha-keto acid dehydrogenase complex (BCKDC), pyruvate dehydrogenase complex (PDC), and alpha-ketoglutarate dehydrogenase complex (KGDC). This is the result of E3 being a common component of all 3 mitochondrial multienzyme complexes. Clinically, affected individuals have lactic acidosis and neurologic deterioration due to sensitivity of the central nervous system to defects in oxidative metabolism. E3 deficiency is often associated with increased urinary excretion of alpha-keto acids, such as pyruvate (summary by Hong et al., 1996). E3 deficiency can also be associated with increased concentrations of branched-chain amino acids, as observed in maple syrup urine disease (MSUD; 248600), and is sometimes referred to as 'MSUD type III,' although patients with E3 deficiency have additional biochemical defects (Chuang and Shih, 2001; Robinson, 2001).  http://www.omim.org/entry/246900
From MedlinePlus Genetics
Dihydrolipoamide dehydrogenase deficiency is a severe condition that can affect several body systems. Signs and symptoms of this condition usually appear shortly after birth, and they can vary widely among affected individuals.

A common feature of dihydrolipoamide dehydrogenase deficiency is a potentially life-threatening buildup of lactic acid in tissues (lactic acidosis), which can cause nausea, vomiting, severe breathing problems, and an abnormal heartbeat. Neurological problems are also common in this condition; the first symptoms in affected infants are often decreased muscle tone (hypotonia) and extreme tiredness (lethargy). As the problems worsen, affected infants can have difficulty feeding, decreased alertness, and seizures. 

Liver problems can also occur in dihydrolipoamide dehydrogenase deficiency, ranging from an enlarged liver (hepatomegaly) to life-threatening liver failure. In some affected people, liver disease, which can begin anytime from infancy to adulthood, is the primary symptom. The liver problems are usually associated with recurrent vomiting and abdominal pain. Rarely, people with dihydrolipoamide dehydrogenase deficiency experience weakness of the muscles used for movement (skeletal muscles), particularly during exercise; droopy eyelids; or a weakened heart muscle (cardiomyopathy). Other features of this condition include excess ammonia in the blood (hyperammonemia), a buildup of molecules called ketones in the body (ketoacidosis), or low blood glucose levels (hypoglycemia).

Typically, the signs and symptoms of dihydrolipoamide dehydrogenase deficiency occur in episodes that may be triggered by fever, injury, or other stresses on the body. Affected individuals are usually symptom-free between episodes. Many infants with this condition do not survive the first few years of life because of the severity of these episodes. Affected individuals who survive past early childhood often have delayed growth and neurological problems, including intellectual disability, muscle stiffness (spasticity), difficulty coordinating movements (ataxia), and seizures.  https://medlineplus.gov/genetics/condition/dihydrolipoamide-dehydrogenase-deficiency

Clinical features

From HPO
Hypertrophic cardiomyopathy
MedGen UID:
2881
Concept ID:
C0007194
Disease or Syndrome
Hypertrophic cardiomyopathy (HCM) is defined by the presence of increased ventricular wall thickness or mass in the absence of loading conditions (hypertension, valve disease) sufficient to cause the observed abnormality.
Hepatomegaly
MedGen UID:
42428
Concept ID:
C0019209
Finding
Abnormally increased size of the liver.
Feeding difficulties
MedGen UID:
65429
Concept ID:
C0232466
Finding
Impaired ability to eat related to problems gathering food and getting ready to suck, chew, or swallow it.
Decreased liver function
MedGen UID:
65430
Concept ID:
C0232744
Finding
Reduced ability of the liver to perform its functions.
Cerebellar ataxia
MedGen UID:
849
Concept ID:
C0007758
Disease or Syndrome
Cerebellar ataxia refers to ataxia due to dysfunction of the cerebellum. This causes a variety of elementary neurological deficits including asynergy (lack of coordination between muscles, limbs and joints), dysmetria (lack of ability to judge distances that can lead to under- or overshoot in grasping movements), and dysdiadochokinesia (inability to perform rapid movements requiring antagonizing muscle groups to be switched on and off repeatedly).
Dystonic disorder
MedGen UID:
3940
Concept ID:
C0013421
Sign or Symptom
An abnormally increased muscular tone that causes fixed abnormal postures. There is a slow, intermittent twisting motion that leads to exaggerated turning and posture of the extremities and trunk.
Lethargy
MedGen UID:
7310
Concept ID:
C0023380
Sign or Symptom
A state of fatigue, either physical or mental slowness and sluggishness, with difficulties in initiating or performing simple tasks. Distinguished from apathy which implies indifference and a lack of desire or interest in the task. A person with lethargy may have the desire, but not the energy to engage in personal or socially relevant tasks.
Seizure
MedGen UID:
20693
Concept ID:
C0036572
Sign or Symptom
A seizure is an intermittent abnormality of nervous system physiology characterized by a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.
Encephalopathy
MedGen UID:
39314
Concept ID:
C0085584
Disease or Syndrome
Encephalopathy is a term that means brain disease, damage, or malfunction. In general, encephalopathy is manifested by an altered mental state.
Global developmental delay
MedGen UID:
107838
Concept ID:
C0557874
Finding
A delay in the achievement of motor or mental milestones in the domains of development of a child, including motor skills, speech and language, cognitive skills, and social and emotional skills. This term should only be used to describe children younger than five years of age.
Increased CSF valine concentration
MedGen UID:
1690599
Concept ID:
C5139572
Finding
Any increased amount from normal of valine in the cerebrospinal fluid.
Increased CSF leucine concentration
MedGen UID:
1689585
Concept ID:
C5139576
Finding
Abnormally increased levels of leucine in cerebrospinal fluid.
Increased CSF isoleucine concentration
MedGen UID:
1699661
Concept ID:
C5139578
Finding
Abnormally increased levels of isoleucine in cerebrospinal fluid.
Hypotonia
MedGen UID:
10133
Concept ID:
C0026827
Finding
Hypotonia is an abnormally low muscle tone (the amount of tension or resistance to movement in a muscle). Even when relaxed, muscles have a continuous and passive partial contraction which provides some resistance to passive stretching. Hypotonia thus manifests as diminished resistance to passive stretching. Hypotonia is not the same as muscle weakness, although the two conditions can co-exist.
Microcephaly
MedGen UID:
1644158
Concept ID:
C4551563
Finding
Head circumference below 2 standard deviations below the mean for age and gender.
Lactic acidosis
MedGen UID:
1717
Concept ID:
C0001125
Disease or Syndrome
An abnormal buildup of lactic acid in the body, leading to acidification of the blood and other bodily fluids.
Hypoglycemia
MedGen UID:
6979
Concept ID:
C0020615
Disease or Syndrome
A decreased concentration of glucose in the blood.
Metabolic acidosis
MedGen UID:
65117
Concept ID:
C0220981
Pathologic Function
Metabolic acidosis (MA) is characterized by a fall in blood pH due to a reduction of serum bicarbonate concentration. This can occur as a result of either the accumulation of acids (high anion gap MA) or the loss of bicarbonate from the gastrointestinal tract or the kidney (hyperchloremic MA). By definition, MA is not due to a respirary cause.
Ketoacidosis
MedGen UID:
67434
Concept ID:
C0220982
Disease or Syndrome
Acidosis resulting from accumulation of ketone bodies.
Elevated circulating hepatic transaminase concentration
MedGen UID:
338525
Concept ID:
C1848701
Finding
Elevations of the levels of SGOT and SGPT in the serum. SGOT (serum glutamic oxaloacetic transaminase) and SGPT (serum glutamic pyruvic transaminase) are transaminases primarily found in the liver and heart and are released into the bloodstream as the result of liver or heart damage. SGOT and SGPT are used clinically mainly as markers of liver damage.
Increased serum pyruvate
MedGen UID:
376596
Concept ID:
C1849488
Finding
An increased concentration of pyruvate in the blood.

Term Hierarchy

CClinical test,  RResearch test,  OOMIM,  GGeneReviews,  VClinVar  

Recent clinical studies

Etiology

Haviv R, Zeharia A, Belaiche C, Haimi Cohen Y, Saada A
Eur J Pediatr 2014 Feb;173(2):243-5. Epub 2013 Aug 31 doi: 10.1007/s00431-013-2153-x. PMID: 23995961
Hinman LM, Sheu KF, Baker AC, Kim YT, Blass JP
Neurology 1989 Jan;39(1):70-5. doi: 10.1212/wnl.39.1.70. PMID: 2909916

Diagnosis

Soreze Y, Boutron A, Habarou F, Barnerias C, Nonnenmacher L, Delpech H, Mamoune A, Chrétien D, Hubert L, Bole-Feysot C, Nitschke P, Correia I, Sardet C, Boddaert N, Hamel Y, Delahodde A, Ottolenghi C, de Lonlay P
Orphanet J Rare Dis 2013 Dec 17;8:192. doi: 10.1186/1750-1172-8-192. PMID: 24341803Free PMC Article
De Meirleir L
Handb Clin Neurol 2013;113:1667-73. doi: 10.1016/B978-0-444-59565-2.00034-4. PMID: 23622387
Brassier A, Ottolenghi C, Boutron A, Bertrand AM, Valmary-Degano S, Cervoni JP, Chrétien D, Arnoux JB, Hubert L, Rabier D, Lacaille F, de Keyzer Y, Di Martino V, de Lonlay P
Mol Genet Metab 2013 May;109(1):28-32. Epub 2013 Feb 1 doi: 10.1016/j.ymgme.2013.01.017. PMID: 23478190
Kerr D, Grahame G, Nakouzi G
Methods Mol Biol 2012;837:93-119. doi: 10.1007/978-1-61779-504-6_7. PMID: 22215543
Brown RM, Head RA, Morris AA, Raiman JA, Walter JH, Whitehouse WP, Brown GK
Dev Med Child Neurol 2006 Sep;48(9):756-60. doi: 10.1017/S0012162206001617. PMID: 16904023

Therapy

Yoo S, Kim JB
Biol Pharm Bull 2015;38(6):913-8. doi: 10.1248/bpb.b14-00712. PMID: 26027833
Carrozzo R, Torraco A, Fiermonte G, Martinelli D, Di Nottia M, Rizza T, Vozza A, Verrigni D, Diodato D, Parisi G, Maiorana A, Rizzo C, Pierri CL, Zucano S, Piemonte F, Bertini E, Dionisi-Vici C
Mitochondrion 2014 Sep;18:49-57. Epub 2014 Sep 22 doi: 10.1016/j.mito.2014.09.006. PMID: 25251739
Rapoport M, Saada A, Elpeleg O, Lorberboum-Galski H
Mol Ther 2008 Apr;16(4):691-7. Epub 2008 Feb 5 doi: 10.1038/mt.2008.4. PMID: 18362926
Craigen WJ
Pediatr Neurol 1996 Jan;14(1):69-71. doi: 10.1016/0887-8994(96)00005-7. PMID: 8652022
Robinson BH, Taylor J, Sherwood WG
Pediatr Res 1977 Dec;11(12):1198-202. doi: 10.1203/00006450-197712000-00006. PMID: 413089

Prognosis

Staretz-Chacham O, Pode-Shakked B, Kristal E, Abraham SY, Porper K, Wormser O, Shelef I, Anikster Y
Nutrients 2021 Oct 7;13(10) doi: 10.3390/nu13103523. PMID: 34684524Free PMC Article
Haviv R, Zeharia A, Belaiche C, Haimi Cohen Y, Saada A
Eur J Pediatr 2014 Feb;173(2):243-5. Epub 2013 Aug 31 doi: 10.1007/s00431-013-2153-x. PMID: 23995961
Patel KP, O'Brien TW, Subramony SH, Shuster J, Stacpoole PW
Mol Genet Metab 2012 Jul;106(3):385-94. doi: 10.1016/j.ymgme.2012.03.017. PMID: 22896851Free PMC Article
Patel KP, O'Brien TW, Subramony SH, Shuster J, Stacpoole PW
Mol Genet Metab 2012 Jan;105(1):34-43. Epub 2011 Oct 7 doi: 10.1016/j.ymgme.2011.09.032. PMID: 22079328Free PMC Article
Imbard A, Boutron A, Vequaud C, Zater M, de Lonlay P, de Baulny HO, Barnerias C, Miné M, Marsac C, Saudubray JM, Brivet M
Mol Genet Metab 2011 Dec;104(4):507-16. Epub 2011 Aug 18 doi: 10.1016/j.ymgme.2011.08.008. PMID: 21914562

Clinical prediction guides

Pinheiro A, Silva MJ, Pavlu-Pereira H, Florindo C, Barroso M, Marques B, Correia H, Oliveira A, Gaspar A, Tavares de Almeida I, Rivera I
Gene 2016 Oct 15;591(2):417-24. Epub 2016 Jun 22 doi: 10.1016/j.gene.2016.06.041. PMID: 27343776
Haviv R, Zeharia A, Belaiche C, Haimi Cohen Y, Saada A
Eur J Pediatr 2014 Feb;173(2):243-5. Epub 2013 Aug 31 doi: 10.1007/s00431-013-2153-x. PMID: 23995961
Brassier A, Ottolenghi C, Boutron A, Bertrand AM, Valmary-Degano S, Cervoni JP, Chrétien D, Arnoux JB, Hubert L, Rabier D, Lacaille F, de Keyzer Y, Di Martino V, de Lonlay P
Mol Genet Metab 2013 May;109(1):28-32. Epub 2013 Feb 1 doi: 10.1016/j.ymgme.2013.01.017. PMID: 23478190
Imbard A, Boutron A, Vequaud C, Zater M, de Lonlay P, de Baulny HO, Barnerias C, Miné M, Marsac C, Saudubray JM, Brivet M
Mol Genet Metab 2011 Dec;104(4):507-16. Epub 2011 Aug 18 doi: 10.1016/j.ymgme.2011.08.008. PMID: 21914562
Odièvre MH, Chretien D, Munnich A, Robinson BH, Dumoulin R, Masmoudi S, Kadhom N, Rötig A, Rustin P, Bonnefont JP
Hum Mutat 2005 Mar;25(3):323-4. doi: 10.1002/humu.9319. PMID: 15712224

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