35 Disorders of Purine and Pyrimidine

Metabolism
Georges van den Berghe, M.- Françoise Vincent, Sandrine Marie

35.1 Inborn Errors of Purine Metabolism – 435

35.1.1 Phosphoribosyl Pyrophosphate Synthetase Superactivity – 435
35.1.2 Adenylosuccinase Deficiency – 436
35.1.3 AICA-Ribosiduria – 437
35.1.4 Muscle AMP Deaminase Deficiency – 437
35.1.5 Adenosine Deaminase Deficiency – 438
35.1.6 Adenosine Deaminase Superactivity – 439
35.1.7 Purine Nucleoside Phosphorylase Deficiency – 440
35.1.8 Xanthine Oxidase Deficiency – 440
35.1.9 Hypoxanthine-Guanine Phosphoribosyltransferase Deficiency – 441
35.1.10 Adenine Phosphoribosyltransferase Deficiency – 442
35.1.11 Deoxyguanosine Kinase Deficiency – 442

35.2 Inborn Errors of Pyrimidine Metabolism – 445

35.2.1 UMP Synthase Deficiency (Hereditary Orotic Aciduria) – 445
35.2.2 Dihydropyrimidine Dehydrogenase Deficiency – 445
35.2.3 Dihydropyrimidinase Deficiency – 446
35.2.4 Ureidopropionase Deficiency – 446
35.2.5 Pyrimidine 5’-Nucleotidase Deficiency – 446
35.2.6 Cytosolic 5’-Nucleotidase Superactivity – 447
35.2.7 Thymidine Phosphorylase Deficiency – 447
35.2.8 Thymidine Kinase Deficiency – 447

References – 447
 434 Chapter 35 · Disorders of Purine and Pyrimidine Metabolism

Purine Metabolism
Purine nucleotides are essential cellular constituents 4 The catabolic pathway starts from GMP, IMP and
which intervene in energy transfer, metabolic regula- AMP, and produces uric acid, a poorly soluble
tion, and synthesis of DNA and RNA. Purine metabo- compound, which tends to crystallize once its
lism can be divided into three pathways: plasma concentration surpasses 6.5–7 mg/dl (0.38–
4 The biosynthetic pathway, often termed de novo, 0.47 mmol/l).
starts with the formation of phosphoribosyl pyro- 4 The salvage pathway utilizes the purine bases, gua-
phosphate (PRPP) and leads to the synthesis of nine, hypoxanthine and adenine, which are pro-
inosine monophosphate (IMP). From IMP, adeno- vided by food intake or the catabolic pathway, and
sine monophosphate (AMP) and guanosine mono- reconverts them into, respectively, GMP, IMP and
phosphate (GMP) are formed. Further metabolism AMP. Salvage of the purine nucleosides, adenosine
(not illustrated) leads to their di- and triphosphates, and guanosine, and their deoxy counterparts, cata-
to their corresponding deoxyribonucleotides, and lyzed by kinases, also occurs.
to RNA and DNA.

VIII

. Fig. 35.1. Pathways of purine metabolism. AICAR, aminoimi- 3, AICAR transformylase; 4, IMP cyclohydrolase (3 and 4 form
dazolecarboxamide ribotide; AMP, adenosine monophosphate; ATIC); 5, adenylosuccinate synthetase; 6, AMP deaminase;
FAICAR, formylaminoimidazolecarboxamide ribotide; GMP, gua- 7, 5c-nucleotidase(s), 8, adenosine deaminase; 9, purine nucleo-
nosine monophosphate; IMP, inosine monophosphate; P, phos- side phosphorylase; 10, hypoxanthine-guanine phosphoribosyl-
phate; PRPP, phosphoribosyl pyrophosphate, S-Ado, succinylade- transferase; 11, adenine phosphoribosyltransferase; 12, adeno-
nosine; SAICAR, succinylaminoimidazolecarboxamide ribotide; sine kinase; 13, guanosine kinase; 14, xanthine oxidase (dehydro-
S-AMP, adenylosuccinate, XMP, xanthosine monophosphate. genase). Enzyme defects are indicated by solid bars across the
1, PRPP synthetase; 2, adenylosuccinase (adenylosuccinate lyase); arrows
35.1 · Inborn Errors of Purine Metabolism
435 35

the first intermediate of the de novo synthesis of purine

Inborn errors exist of the biosynthetic, catabolic, and nucleotides (not shown in full detail in . Fig. 35.1), which
salvage pathways of purine and pyrimidine metabo- leads to the formation of inosine monosphosphate (IMP),
lism, which are depicted in . Fig. 35.1 and 35.3, respec- from which the other purine compounds are derived. PRPP
tively. The major presenting signs and laboratory find- synthetase is highly regulated. Various genetic regulatory
ings in these inborn errors are listed in . Table 35.1. and catalytic defects [1, 2] lead to superactivity, resulting in
increased generation of PRPP. Because PRPP amidotrans-
ferase, the rate-limiting enzyme of the de novo pathway, is
physiologically not saturated by PRPP, the synthesis of
35.1 Inborn Errors of Purine purine nucleotides increases, and hence the production of
Metabolism uric acid. PRPP synthetase superactivity is one of the few
known examples of an hereditary anomaly of an enzyme
Inborn errors of purine metabolism comprise errors of: which enhances its activity. The mechanism of the neuro-
4 purine nucleotide synthesis: phosphoribosylpyrophos- logical symptoms is unresolved.
phate (PRPP) synthetase superactivity, adenylosuc-
cinase (ADSL) deficiency, AICA-ribosiduria caused by Genetics
ATIC deficiency; The various forms of PRPP synthetase superactivity are
4 purine catabolism: the deficiencies of muscle AMP inherited as X-linked traits. In the families in which the
deaminase (AMP-DA, also termed myoadenylate de- anomaly is associated with sensorineural deafness, hetero-
aminase), adenosine deaminase (ADA), purine nuc- zygous females have also been found with gout and/or
leoside phosphorylase (PNP) and xanthine oxidase; hearing impairment [2]. Studies of the gene in six families
4 purine salvage: the deficiencies of hypoxanthine-gua- revealed a different single base change in each of them [3].
nine phosphoribosyltransferase (HGPRT) and adenine
phosphoribosyltransferase (APRT). The deficiency of Diagnostic Tests
deoxyguanosine kinase causes mitochondrial DNA Diagnosis requires extensive kinetic studies of the enzyme,
depletion (7 also Chap. 15). which are performed on erythrocytes and cultured fibro-
blasts in a few laboratories in the world. The disorder should
With the exception of muscle AMP-DA deficiency, all these be differentiated from partial HGPRT deficiency, which
enzyme defects are very rare. gives similar clinical signs.

Treatment and Prognosis

35.1.1 Phosphoribosyl Pyrophosphate Patients should be treated with allopurinol, which inhibits
Synthetase Superactivity xanthine oxidase, the last enzyme of purine catabolism
(. Fig. 35.1). This results in a decrease of the production of
Clinical Presentation uric acid and in its replacement by hypoxanthine, which is
The disorder is mostly manifested by the appearance, about 10-fold more soluble, and xanthine, which is slightly
in young adult males, of gouty arthritis and/or uric acid more soluble than uric acid. Initial dosage of allopurinol is
lithiasis, potentially leading to renal insufficiency [1, 2]. 10–20 mg/kg per day in children and 2–10 mg/kg per day
Uricemia can be very high, reaching 10–15 mg/dl (0.60– in adults. It should be adjusted to the minimum required to
0.90 mmol/l) [normal adult values: 2.9–5.5 mg/dl (0.17– maintain normal uric acid levels in plasma, and reduced
0.32 mmol/l)]. The urinary excretion of uric acid is also in subjects with renal insufficiency. In rare patients with a
increased, reaching up to 2400 mg (14 mmol)/24 h, or considerable increase in de novo synthesis, xanthine calculi
2.5 mmol/mmol creatinine [normal adult values: 500– can be formed during allopurinol therapy [4]. Consequently,
800 mg (3-4.7 mmol)/24 h, or 02–0.3 mmol/mmol creati- additional measures to prevent cristallization are recom-
nine]. mended. These include a low purine diet (free of organ
A few patients have been reported in which clinical meats, fishes such as anchovy, herring, mackerel, salmon,
signs of uric acid overproduction already appeared in in- sardines and tuna, dried beans and peas), high fluid intake
fancy and were accompanied by neurologic abnormalities, and, since uric acid and xanthine are more soluble at alka-
mainly sensorineural deafness, particularly for high tones, line than at acid pH, administration of sodium bicarbonate,
but also hypotonia, locomotor delay, ataxia and autistic potassium citrate or citrate mixtures to bring urinary pH to
features [2]. 6.0-6.5. Adequate control of the uricemia prevents gouty
arthritis and urate nephropathy, but does not correct the
Metabolic Derangement neurological symptoms.
The enzyme forms phosphoribosyl pyrophosphate (PRPP)
from ribose-5-phosphate and ATP (. Fig. 35.1). PRPP is
 436 Chapter 35 · Disorders of Purine and Pyrimidine Metabolism

. Table 35.1. Main presenting clinical signs and laboratory data in inborn errors of purine and pyrimidine metabolism

Clinical signs Diagnostic possibilities Clinical signs Diagnostic possibilities

Arthritis PRPP synthetase superactivity Muscle cramps Muscle AMP deaminase deficiency
HGPRT deficiency (partial) Muscle wasting Adenylosuccinase deficiency
Ataxia PNP deficiency Psychomotor delay PRPP synthetase superactivity
HGPRT deficiency (complete) Adenylosuccinase deficiency
Cytosolic 5’-nucleotidase superactivity AICA-ribosiduria (ATIC deficiency)
Autistic features PRPP synthetase superactivity Combined xanthine and sulfite oxidase
Adenylosuccinase deficiency deficiency
Dihydropyrimidine dehydrogenase HGPRT deficiency (complete)
deficiency UMP synthase deficiency
Cytosolic 5’-nucleotidase superactivity Dihydropyrimidine dehydrogenase
Congenital blindness AICA-ribosiduria (ATIC deficiency) deficiency
Convulsions Adenylosuccinase deficiency Dihydropyrimidinase deficiency
Combined xanthine and sulfite Ureidopropionase deficiency
oxidase deficiency Cytosolic 5’-nucleotidase superactivity
Dihydropyrimidine dehydrogenase Recurrent infections ADA deficiency
deficiency PNP deficiency
Dihydropyrimidinase deficiency Cytosolic 5’-nucleotidase superactivity
Cytosolic 5’-nucleotidase superactivity Renal insufficiency PRPP synthetase superactivity
Deafness PRPP synthetase superactivity HGPRT deficiency (complete or partial)
Dysmorphic features AICA-ribosiduria (ATIC deficiency) APRT deficiency
Growth retardation Adenylosuccinase deficiency Self-mutilation HGPRT deficiency (complete)
VIII ADA deficiency
UMP synthase deficiency Laboratory data Diagnostic possibilities
Dihydropyrimidine dehydrogenase Anemia
deficiency Megaloblastic UMP synthase deficiency
Cytosolic 5’-nucleotidase superactivity Hemolytic ADA superactivity
Hypotonia Adenylosuccinase deficiency Pyrimidine 5’-nucleotidase deficiency
Muscle AMP deaminase deficiency Hyperuricemia PRPP synthetase superactivity
Ureidopropionase deficiency HGPRT deficiency (complete or partial)
Kidney stones: Hypouricemia PNP deficiency
Uric acid PRPP synthetase superactivity Xanthine oxidase deficiency (isolated or
HGPRT deficiency (complete or partial) combined with sulfite oxidase deficiency)
Xanthine Xanthine oxidase deficiency (isolated Lymphopenia
or combined with sulfite oxidase B and T-cells ADA deficiency
deficiency) T-cells PNP deficiency
2,8-Dihydroxyadenine APRT deficiency Orotic aciduria UMP synthase deficiency
Orotic acid UMP synthase deficiency

ADA, adenosine deaminase; APRT, adenine phosphoriboysltransferase; ATIC, AICAR transformylase/IMP cyclohydrolase; HGPRT, hypo-
xanthine-guanine phosphoribosyltransferase; PNP, purine nucleoside phosphorylase; PRPP, phosphoribosyl pyrophosphate; UMP,
uridine monophosphate.

35.1.2 Adenylosuccinase Deficiency ciency in unexplained, profound as well as mild psychomo-

tor retardation, and in neurological disease with convul-
Clinical Picture sions and/or hypotonia.
In the first reported presentation, often referred to as type
I, patients display moderate to severe psychomotor retar- Metabolic Derangement
dation, frequently accompanied by epilepsy after the first Adenylosuccinase (ADSL, also named adenylosuccinate
years, and by autistic features (failure to make eye-to-eye lyase), catalyzes two steps in purine synthesis (. Fig. 35.1):
contact, repetitive behavior, temper tantrums), seldom by the conversion of succinylamino-imidazole carboxamide
severe growth retardation associated with muscular wasting ribotide (SAICAR) into AICAR, along the de novo pathway,
[5, 6]. Rare patients, referred to as type II, are only mildly and that of adenylosuccinate (S-AMP) into AMP. Its defi-
retarded [6], or display profound muscle hypotonia accom- ciency results in accumulation in cerebrospinal fluid and
panied by slightly delayed motor development [7]. Other urine of the succinylpurines, SAICA riboside and succinyl-
patients have been reported with convulsions starting with- adenosine (S-Ado), the products of the dephosphorylation,
in the first days to weeks of life [8, 9]. The marked clinical by 5c-nucleotidase(s), of the two substrates of the enzyme.
heterogeneity justifies systematic screening for the defi- Present evidence indicates that the more severe presenta-
35.1 · Inborn Errors of Purine Metabolism
437 35

tions of ADSL deficiency tend to be associated with S-Ado/ mmol/kg per day) has been reported to reduce seizure fre-
SAICA riboside ratios around 1, whereas in milder clinical quency in an ADSL-deficient girl [18]. Uridine (2 mmol/kg
pictures these ratios are comprised between 2 and 4. This per day) also had a slight beneficial effect [19].
suggests that SAICA riboside is the offending compound, The prognosis for survival of ADSL-deficient patients is
and that S-Ado could protect against its toxic effects. The very variable. Mildly retarded patients have reached adult
ADSL defect is marked in liver and kidney, and variably ex- age, whereas several of those presenting with early epilepsy
pressed in erythrocytes, muscle, and fibroblasts [5, 6, 9]. The have died within the first months of life.
higher S-Ado/SAICA riboside ratios might be explained
by a more profound loss of activity of the enzyme toward
S-AMP than toward SAICAR, as compared with a parallel 35.1.3 AICA-Ribosiduria
deficiency in severely affected patients [9]. The symptoms of
the deficiency remain unexplained, but positron emission In a female infant [20] with profound mental retardation,
tomography reveals a marked decrease of the uptake of marked dysmorphic features (prominent forehead and me-
fluorodeoxyglucose in the cortical brain areas [10]. topic suture, brachycephaly, wide mouth with thin upper
lip, low-set ears, and prominent clitoris due to fused labia
Genetics majora), and congenital blindness, a positive urinary Brat-
The deficiency is transmitted as an autosomal recessive trait ton-Marshall test led to the identification of a massive
[5, 6]. Studies of the ADSL gene, localized on chromosome excretion of 5-amino-4-imidazolecarboxamide (AICA)-
22, have led to the identification of about 40 mutations [11- riboside, the dephosphorylated counterpart of AICAR
13] (ADSL mutations database home page, http://www.icp. (. Fig. 35.1). Assay of ATIC, the bifunctional enzyme cata-
ucl.ac.be/adsldb/). Most are missense mutations but a splic- lyzing the two last steps of de novo purine biosynthesis, re-
ing error [12] and a mutation in the 5cUTR [14] have also vealed a profound deficiency of AICAR transformylase, and
been identified. Most frequently encountered, particularly a partial deficiency of IMP cyclohydrolase. Sequencing of
in The Netherlands, and accounting for about one-third of the ATIC gene showed a K426R change in the transformy-
the alleles investigated, is a R462H mutation. Most other lase region in one allele, and a frameshift in the other. The
mutations are found in single families, in which most pa- discovery of this novel inborn error of purine synthesis
tients are compound heterozygotes. reinforces the necessity to perform a Bratton-Marshall test
[15] in all cases of unexplained mental retardation and/or
Diagnostic Tests neurological symptoms.
Diagnosis is based on the presence in cerebrospinal fluid
and urine of SAICA riboside and S-Ado, which are nor-
mally undetectable. These can be recognized by various 35.1.4 Muscle AMP Deaminase Deficiency
techniques. For systematic screening, a modified Bratton-
Marshall test [15], performed on urine, appears most prac- Clinical Picture
tical. False positive results are, however, recorded in patients The deficiency of muscle AMP deaminase (AMP-DA, fre-
who receive sulphonamides, for the measurement of which quently referred to as myoadenylate deaminase in the clini-
the test was initially devised. Several thin-layer chromato- cal literature) is present in 1-2% of the Caucasian popula-
graphic methods are also available [16]. Final diagnosis tion. Most deficient individuals are asymptomatic. Never-
requires HPLC with UV detection [5]. Prenatal diagnosis of theless, some subjects, in whom the AMP-DA defect is
ADSL deficiency can be performed by mutation analysis on termed primary, present with isolated muscular weakness,
chorion villi [17]. fatigue, cramps or myalgias following moderate to vigorous
exercise, sometimes accompanied by an increase in serum
Treatment and Prognosis creatine kinase and minor electromyographic abnormali-
With the aim to replenish hypothetically decreased concen- ties [21]. Muscular wasting or histological abnormalities are
trations of adenine nucleotides in ADSL-deficient tissues, absent. Primary AMP-DA deficiency was initially detected
some patients have been treated for several months with in young adults, but later on wide variability was observed
oral supplements of adenine (10 mg/kg per day) and al- with respect to the age (1.5-70 years) of onset of the symp-
lopurinol (5-10 mg/kg per day). Adenine can be incorpo- toms [22, 23]. Moreover, the enzyme defect has been de-
rated into the adenine nucleotides via adenine phosphori- tected in patients with hypotonia and/or cardiomyopathy,
bosyltransferase (APRT, . Fig. 35.1). Allopurinol is required and in asymptomatic family members of subjects with the
to avoid conversion of adenine by xanthine oxidase, into disorder. Secondary AMP-DA deficiency is found in asso-
minimally soluble 2,8-dihydroxyadenine, which forms kid- ciation with several neuromuscular disorders amongst
ney stones. No clinical or biochemical improvement was which amyotrophic lateral sclerosis, fascioscapulohumeral
recorded, with the exception of weight gain and some ac- myopathy, Kugelberg-Welander syndrome, polyneuropa-
celeration of growth [6]. Oral administration of ribose (10 thies, and Werdnig-Hoffmann disease [22, 23].
 438 Chapter 35 · Disorders of Purine and Pyrimidine Metabolism

Metabolic Derangement Diagnostic Tests

AMP-DA, adenylosuccinate synthetase and adenylosucci- Screening for the defect can be performed by an exercise
nase form the purine nucleotide cycle (. Fig. 35.2). Numer- test (7 Chap. 3). A several-fold elevation of venous plasma
ous functions have been proposed for this cycle in muscle ammonia, seen in normal subjects, is absent in AMP-DA
(reviewed in [24]): (a) removal of AMP formed during ex- deficiency. Final diagnosis is established by histochemical
ercise, in order to favor the formation of ATP from ADP by or biochemical assay in a muscle biopsy. In the primary
myokinase (adenylate kinase); (b) release of NH3 and IMP, defect, the activity of AMP-DA is below 2% of normal, and
both stimulators of glycolysis and hence of energy produc- little or no immunoprecipitable enzyme is found. In the
tion; (c) production of fumarate, an intermediate of the secondary defect, the activity is 2–15% of normal, and usu-
citric acid cycle, which also yields energy. It has therefore ally appreciable immunoreactivity is present [29]. In sev-
been proposed that the muscle dysfunction observed in pri- eral large series of muscle biopsies for diagnostic purposes,
mary AMP-DA deficiency is caused by impairment of en- low enzyme activities were found in about 2% of all speci-
ergy production for muscle contraction. However, this does mens [22, 23].
not tally with the vast number of asymptomatic AMP-DA-
deficient individuals, and suggests that the deficiency might Treatment and Prognosis
have a synergistic effect in association with other hitherto Patients may display a gradual progression of their symp-
unidentified disorder(s). toms, which may lead to the point that even dressing and
It should be noted that muscle, liver and erythrocytes walking a few steps lead to fatigue and myalgias. They
contain different isoforms of AMP-DA. A regulatory muta- should be advised to exercise with caution to prevent rhab-
tion of liver AMP-DA has been proposed as a cause of domyolysis and myoglobinuria. Administration of ribose
primary gout with overproduction of uric acid [25]. Indi- (2–60 g per day orally in divided doses) has been reported
VIII viduals with a complete, although totally asymptomatic to improve muscular strength and endurance [30].
deficiency of erythrocyte AMP-DA have been detected in
Japan, Korea and Taiwan [26].
35.1.5 Adenosine Deaminase Deficiency
Genetics
Primary AMP-DA deficiency is apparently transmitted as Clinical Picture
an autosomal recessive trait. AMPD1, the gene encoding The majority of patients display, within the first weeks or
muscle AMP-DA, is located on chromosome 1. In most in- months after birth, a profound impairment of both humor-
dividuals with the primary deficiency the defect is caused al and cellular immunity, known as severe combined immu-
by a nonsense c.34CoT mutation resulting in a stop codon nodeficiency disease (SCID). Multiple, recurrent infections
[27]. Population studies show that this mutant allele is rapidly become life-threatening [31, 32]. Cases with delayed
found with a high frequency in Caucasians. This accords infantile onset, later childhood onset, and even adult onset
with the finding that about 2% of diagnostic muscle biopsies have, nevertheless, been reported. Caused by a broad vari-
are AMP-DA deficient, and suggests that the mutation arose ety of organisms, infections are mainly localized in the skin,
in a remote Western European ancestor. More recently, the respiratory and the gastrointestinal tract. In the latter
other more rare mutations of the AMPD1 gene have been they often lead to intractable diarrhea, malnutrition and
identified in AMP-DA deficient individuals. Interestingly, growth retardation. In affected children over 6 months of
mutations of the AMPD1 gene seem associated with im- age, hypoplasia or apparent absence of lymphoid tissue is
proved outcome in heart diseases [28]. a suggestive sign. Bone abnormalities, clinically evident as
prominence of the costochondral rib junctions, and radio-
logically as cupping and flaring thereof, are found in about
half of the patients. In a few affected children neurological
abnormalities are found, including spasticity, head lag,
movement disorders, nystagmus and inability to focus. He-
patic dysfunction has also been reported [32, 33].
SCID can be confirmed by relatively simple laboratory
tests: lymphopenia (usually less than 500 total lymphocytes
per mm3) involving both B and T cells, as well as hypogam-
maglobulinemia are almost invariably present. Whereas the
. Fig. 35.2. The purine nucleotide cycle. IMP, inosine monophos- IgM deficiency may be detected early, the IgG deficiency
phate; S-AMP, adenylosuccinate; AMP, adenosine monophosphate;
becomes manifest only after the age of 3 months, when the
ADP, adenosine diphosphate; ATP, adenosine triphosphate; Asp,
aspartate; Fum, fumarate. 1, Adenylosuccinate synthetase; 2, adenylo- maternal supply has been exhausted. More elaborate tests
succinase; 3, AMP deaminase; 4, also shown is myokinase (adenylate show a deficiency of antibody formation following specific
kinase) immunization and an absence or severe diminution of the
35.1 · Inborn Errors of Purine Metabolism
439 35

lymphocyte proliferation induced by mitogens. The disease bone marrow transplantation. This remains the first choice
is progressive, since residual B- and T-cell function which provided an histocompatible donor is available, and gives a
may be found at birth, disappears later on. good chance for complete cure, both clinically and immu-
nologically [36]. The graft provides stem cells, and hence T
Metabolic Derangement and B cells, which have sufficient ADA activity to prevent
The deficiency results in the accumulation in body fluids of accumulation of adenosine and deoxyadenosine. Survival
adenosine, normally nearly undetectable (. Fig. 35.1), and is, however, much lower with HLA-mismatched trans-
deoxyadenosine (not shown in . Fig. 35.1), another sub- plants.
strate of adenosine deaminase (ADA), derived from the If no histocompatible bone marrow donor is found, en-
catabolism of DNA. Inside lymphocytes, deoxyadenosine zyme replacement therapy can be given. Repeated partial
excess leads to accumulation of dATP which inhibits ribo- exchange transfusions with normal erythrocytes, irradiated
nucleotide reductase, an essential enzyme for the synthesis before use to prevent graft-versus-host disease, result in
of DNA which has to proceed at a high rate during lym- marked clinical and immunological improvement in some
phocyte development and differentiation. More recently, patients, but in most response is poor or not sustained [36].
dATP has also been reported to provoke thymic T-cell ap- A much more effective enzyme replacement therapy is
optosis [34]. Deoxyadenosine has moreover been shown achieved with polyethylene glycol-modified ADA (PEG-
to inactivate S-adenosylhomocysteine hydrolase [32], an ADA). Covalent attachment of PEG to bovine ADA results
enzyme which intervenes in methyl transfer, but how this in marked extension of its half-life, and reduction of im-
affects lymphocyte function remains elusive. munogenicity. Weekly to bi-weekly intramuscular injec-
tions of 15–30 units of PEG-ADA per kg result in mostly
Genetics marked clinical improvement. In vitro immune function
Approximately 1/3 of the cases of inherited SCID are also significantly improves [37].
X-linked, whereas 2/3 are autosomal recessive. ADA defi- The first approved clinical trial of gene therapy was
ciency is found only in the latter group, where it accounts performed in 1990 in two girls with ADA deficiency [38].
for about 50% of the patients. The frequency of the defi- Their peripheral blood T cells were collected, cultured with
ciency is estimated at 1 per 100,000-500,000 births. Studies interleukin-2, corrected by insertion of the ADA gene by
of the ADA gene, located on chromosome 20, have hitherto means of a retroviral vector, and reinfused. Because lym-
revealed over 70 mutations, the majority of which are single phocytes live only a few months, 11 or 12 infusions were
nucleotide changes, resulting in an either inactive or un- given over two years to each patient. The number of T cells
stable enzyme [32]. Most patients carry two different muta- normalized, as did many cellular and humoral immune
tions on each chromosome 20, but others, mainly from in- responses, no adverse events were observed and, remark-
bred communities, are homozygous for the mutation. Spon- ably, 10 years after the last cell infusion expression of the
taneous in vivo reversion to normal of a mutation on one retroviral gene was still present [39]. Since as a precaution,
allele, as observed in tyrosinemia type I (7 Chap. 18), has patients continued to receive PEG-ADA although at re-
been reported [35]. duced doses, benefits cannot be attributed unequivocally to
gene therapy.
Diagnostic Tests More recently, successful correction of ADA deficiency
The diagnosis is mostly performed on red blood cells. In has been accomplished by gene therapy into hematopoietic
general, severity of disease correlates with the loss of ADA stem cells which in theory have an unlimited life span, with-
activity: children with neonatal onset of SCID display 0–1% out concomitant PEG-ADA treatment, and with addition of
residual activity; in individuals with later onset, 1–5% of a low-intensity, nonmyeloablative conditioning regimen
normal ADA activity are found [32]. It should be noted that [40]. It should be mentioned that gene therapy in X-linked,
only about 15% of the patients with the clinical and hema- not ADA deficient SCID, although highly effective, as been
tologic picture of inherited SCID are ADA-deficient. In the placed on hold due to the development of leukemia in some
remaining patients, SCID is caused by other mechanisms. patients [41].
A few subjects have been described with ADA deficiency in
red blood cells, but normal immunocompetence [32]. This
is explained by the presence of residual ADA activity in 35.1.6 Adenosine Deaminase Super-
their lymphocytes. activity

Treatment and Prognosis A hereditary, approx. 50-fold elevation of red cell ADA, has
Untreated, ADA deficiency as a rule invariably led to death, been shown to cause non-spherocytic hemolytic anaemia
usually within the first year of life, unless drastic steps were [42]. The latter can be explained by an enhanced catabolism
taken, such as rearing in strictly sterile conditions from of the adenine nucleotides, including ATP, owing to the
birth on. Treatment became possible with the advent of increased activity of ADA.
 440 Chapter 35 · Disorders of Purine and Pyrimidine Metabolism

36.1.7 Purine Nucleoside Phosphorylase reported [46]. Enzyme and gene therapy might become
Deficiency available in the near future.

Clinical Picture
Recurrent infections are usually of later onset, starting 35.1.8 Xanthine Oxidase Deficiency
from the end of the first year to up to 5-6 years of age, and
are initially less severe than in ADA deficiency [43, 44]. A Clinical Picture
strikingly enhanced susceptibility to viral diseases, such Two deficiencies of xanthine oxidase (or dehydrogenase)
as varicella, measles, cytomegalovirus and vaccinia has are known: an isolated form [47],also termed hereditary
been reported, but severe candida and pyogenic infections xanthinuria, and a combined xanthine oxidase and sulfite
also occur. One third of the patients have anemia, and two oxidase deficiency [48]. Isolated xanthine oxidase deficien-
thirds display neurologic symptoms, including spastic cy can be completely asymptomatic, although in about one
tetra- or diplegia, ataxia and tremor. Immunological stud- third of the cases kidney stones are formed. Most often not
ies reveal an increasing deficiency of cellular immunity, visible on X-ray, they may appear at any age. Myopathy may
reflected by a marked reduction in the number of T-cells. be present, associated with crystalline xanthine deposits. In
B-lymphocyte function is deficient in about one third of the combined deficiency, the clinical picture of sulfite oxi-
the patients. dase deficiency (which is also found as an isolated defect
[49], 7 Chap. 21) dominates that of the xanthine oxidase
Metabolic Derangement deficiency. The symptoms include neonatal feeding diffi-
The deficiency provokes an accumulation in body fluids of culties and intractable seizures, myoclonus, increased or
the 4 substrates of the enzyme which are normally nearly decreased muscle tone, eye lens dislocation and severe men-
VIII undetectable, namely guanosine, inosine (. Fig. 35.1), and tal retardation.
their deoxycounterparts (not shown in . Fig. 35.1), the lat-
ter derived from DNA breakdown. Formation of uric acid Metabolic Derangement
is thus severely hampered. The profound impairment of The deficiency results in the near total replacement of uric
cellular immunity, characterizing the disorder, has been acid by hypoxanthine and xanthine as the end products
explained by an accumulation, particularly in T-cells, of of purine catabolism (. Fig. 35.1). Hereditary xanthinuria
excess dGTP. It is formed from deoxyguanosine, inhibits can result from a deficiency of xanthine oxidase (type I)
ribonucleotide reductase, and hence cell division. or of both xanthine oxidase and aldehyde oxidase (type II).
The latter is a closely related enzyme that metabolizes
Genetics synthetic purine analogues such as allopurinol. In com-
The deficiency is inherited in an autosomal recessive fash- bined xanthine oxidase and sulfite oxidase deficiency there
ion. Studies of the PNP gene, located on chromosome 14, is in addition an accumulation of sulfite and of sulfur-con-
have revealed a number of molecular defects, among which taining metabolites, and a diminution of the production
a R234P mutation was most common [45]. of inorganic sulfate. The combined defect is caused by
the deficiency of a molybdenum cofactor, which is required
Diagnostic Tests for the activity of both xanthine oxidase and sulfite oxi-
Patients often display a striking decrease of the production dase.
of uric acid: plasma uric acid is usually below 1 mg/dl and
may even be undetectable. However, in patients with re- Genetics
sidual PNP activity, uricemia may be at the borderline of The inheritance of both isolated xanthine oxidase deficien-
normal. The urinary excretion of uric acid is usually also cy and combined xanthine oxidase and sulfite oxidase defi-
markedly diminished. Other causes of hypouricemia such ciency is autosomal recessive. Studies of the xanthine oxi-
as xanthine oxidase deficiency (7 below), and drug admin- dase gene, localized on chromosome 2, have led to the iden-
istration (acetylsalicylic acid, thiazide diuretics), should be tification in hereditary xanthinuria type I of two mutations,
ruled out. Enzymatic diagnosis of PNP deficiency is usually resulting in a nonsense substitution and a termination co-
performed on red blood cells. don, respectively [50]. Xanthinuria type II might be caused
by mutation of a molybdenum cofactor sulferase gene [51].
Treatment and Prognosis More than 30 different mutations in three molybdenum
Until recently, most patients have died from overwhelming cofactor biosynthetic genes have been identified in com-
viral or bacterial infections, although at a later age than un- bined xanthine oxidase and sulfite oxidase deficiency [52].
treated ADA-deficient children. Treatments consisted of
bone marrow transplantation and repeated transfusions Diagnostic Tests
of normal, irradiated erythrocytes [36, 44]. More recently, Both in isolated and combined xanthine oxidase deficiency,
successful matched bone marrow transplantation has been plasma concentrations of uric acid below 1 mg/dl (0.06
35.1 · Inborn Errors of Purine Metabolism
441 35

mmol/L) are measured; they may decrease to virtually un- Metabolic Derangement
detectable values on a low-purine diet. Urinary uric acid is The considerable increase of the production of uric acid
reduced to a few percent of normal and replaced by hypox- is explained as follows: PRPP, which is not utilized at the
anthine and xanthine. In the combined defect, these urinary level of HGPRT (. Fig. 35.1), is available in increased
changes are accompanied by an excessive excretion of sulfite quantities for the rate limiting, first enzyme of the de
and other sulfur-containing metabolites, such as S-sulfo- novo synthesis, PRPP amidotransferase (not shown in
cysteine, thiosulfate and taurine. The enzymatic diagnosis . Fig. 35.1). Since the latter is normally not saturated with
requires liver or intestinal mucosa, the only human tissues PRPP, its activity increases and the ensuing acceleration
which normally contain appreciable amounts of xanthine of the de novo synthesis results in the overproduction of
oxidase. Sulfite oxidase and the molybdenum cofactor can uric acid.
be assayed in liver and fibroblasts. The pathogenesis of the neurological symptoms is still
not satisfactorily explained. A number of studies point to
Treatment and Prognosis dopaminergic dysfunction, involving decreases of the con-
Isolated xanthine oxidase deficiency is mostly benign but in centration of dopamine and of the activity of the enzymes
order to prevent renal stones a low purine diet should be required for its synthesis, although dopaminergic drugs
prescribed and fluid intake increased. The prognosis of are not useful. Positron emission tomography of the brain
combined xanthine oxidase and sulfite oxidase deficiency is with F-18 fluorodopa, an analogue of the dopamine pre-
very poor. So far, all therapeutic attempts, including low- cursor levodopa, has revealed a generalized decrease of the
sulfur diets, the administration of sulfate and molybdenum activity of dopa decarboxylase [55]. How the HGPRT defect
[48], and trials to bind sulfite with thiol-containing drugs, leads to the deficit of the dopaminergic system, and how
have been unsuccessful. the latter results in the characteristic neuropsychiatric
manifestations of the Lesch-Nyhan syndrome, remains to
be clarified.
35.1.9 Hypoxanthine-Guanine
Phosphoribosyltransferase Genetics
Deficiency Both the Lesch-Nyhan syndrome and the partial deficien-
cies of HGPRT are transmitted in a X-linked recessive man-
Clinical Picture ner. Studies of the HGPRT gene in large groups of unrelated
The disorder can present under two forms. Patients with patients have revealed a variety of defects, ranging from
complete or near-complete deficiency of hypoxanthine- point mutations provoking single amino acid substitutions
guanine phosphoribosyltransferase (HGPRT) display the and henceforth enzymes with altered stability and/or
Lesch-Nyhan syndrome [53]. Affected children generally kinetic properties, to extensive deletions resulting in sup-
appear normal during the first months of life. At 3 to 4 pression of enzyme synthesis [56]. These studies have con-
months of age, a neurological syndrome evolves, which in- tributed a great deal to the understanding of the clinical
cludes delayed motor development, choreo-athetoid move- variation observed in human inherited disease, and pro-
ments, and spasticity with hyperreflexia and scissoring. vided support for the concept that, in X-linked disorders,
Over the years, the patients develop a striking, compulsive new mutations constantly appear in the population. Pre-
self-destructive behavior, involving biting of their fingers sently, over 250 mutations of the HGPRT gene have been
and lips, which leads to mutilating loss of tissue. Speech is described, and molecular studies have led to precise pre-
hampered by athetoid dysarthria. Whereas most patients natal diagnosis and efficient carrier testing of at-risk
have IQ’s around 50, some display normal intelligence. Ap- females [57].
proximately 50% of the patients have seizures. Soon or later
they form uric acid stones. Mothers of Lesch-Nyhan pa- Diagnostic Tests
tients have reported the finding of orange crystals on their Patients excrete excessive amounts of uric acid, ranging
affected son’s diapers during the first few weeks after birth. from 25 to 140 mg (0.15 to 0.85 mmol)/kg of body weight
Untreated, the uric acid nephrolithiasis progresses to ob- per 24 h, as compared to an upper limit of 18 mg (0.1 mmol)/
structive uropathy and renal failure during the first decade kg per 24 h in normal children. Determination of the ratio
of life. The latter clinical picture may, exceptionally, also be of uric acid to creatinine (mg/mg) in morning samples of
observed in early infancy. urine provides a screening test. This ratio is much higher in
Partial HGPRT deficiency is found in rare patients with HGPRT deficiency than the normal upper limits of 2.5, 2.0,
gout. Most of them are normal on neurological examination, 1.0 and 0.6 for infants, 2 years, 10 years and adults, respec-
but occasionally spasticity, dysarthria and a spinocerebellar tively [58]. Increased ratios are also found in other disorders
syndrome are found [54]. Whereas most patients with the with uric acid overproduction, such as PRPP synthetase
Lesch-Nyhan syndrome do not develop gouty arthritis, this superactivity, glycogenosis type I, lymphoproliferative di-
finding is common in partial HGPRT deficiency. seases, and after fructose loading. The overproduction of
 442 Chapter 35 · Disorders of Purine and Pyrimidine Metabolism

uric acid is as a rule accompanied by an increase of serum pathway (not shown in . Fig. 35.1). Consequently, adenine
urate, which may reach concentrations as high as 18 mg/dl is oxidized by xanthine oxidase into 2,8-dihydroxyadenine,
(1 mmol/L). Occasionally, however, particularly before pub- a very poorly soluble compound (solubility in urine, at pH
erty, uricemia may be in the normal or high normal 5 and 37°C, is about 0.3 mg/dl as compared to 15 mg/dl for
range. uric acid).
Patients with the Lesch-Nyhan syndrome display near- The deficiency can be complete or partial. The par-
ly undetectable HGPRT activity in red blood cells [59]. In tial deficiency is only found in the Japanese, among
partial deficiencies, similar low or higher values may be whom it is quite common [67]. Activities range from 10
found [60]. Rates of incorporation of hypoxanthine into the to 30% of normal at supraphysiological concentrations
adenine nucleotides of intact fibroblasts correlate better of PRPP, but a 20- to 30-fold decrease in the affinity for
with the clinical symptomatology than HGPRT activities in PRPP results in near inactivity under physiological con-
erythrocytes: patients with the complete Lesch-Nyhan syn- ditions.
drome incorporated less than 1.2% of normal, those with
gout and neurological symptoms 1.2–10% of normal, and Genetics
those with isolated gout, 10–55% of normal [60]. APRT deficiency is inherited as an autosomal recessive trait.
All the type II Japanese patients carry the same c.2069T oC
Treatment and Prognosis substitution in exon 5, resulting in a M136T change [67].
Allopurinol, as detailed under PRPP synthetase superactiv- Approximately 80% are homogenous, with two other mu-
ity, is indicated to prevent urate nephropathy. Allopurinol, tations accounting for nearly all the other cases. In Cauca-
even when given from birth, has, however, no effect on the sians, approximately 30 mutations have been identified,
neurological symptoms, which have sofar been resistant to some of which seem more common, also suggesting found-
VIII all therapeutic attempts. Adenine has been administered, er effects [68].
together with allopurinol, with the aim to correct a possible
depletion of purine nucleotides. However, no or minimal Diagnostic Tests
changes in neurological behavior were recorded [61]. Pa- Identification of 2,8-dihydroxyadenine requires complex
tients should be made more comfortable by appropriate analyses, including UV and infrared spectrography, mass
restraints, including elbow splints, lip guards and even tooth spectrometry and X-ray cristallography [64, 65]. It is there-
extraction, to diminish self-mutilation. Diazepam, halo- fore usually easier to measure APRT activity in red blood
peridol and barbiturates may sometimes improve chore- cells.
oathetosis.
In a 22-year-old patient, bone marrow transplantation Treatment and Prognosis
restored erythrocyte HGPRT activity to normal, but did not In patients with symptoms, allopurinol should be given, as
change neurological symptoms [62]. Recently, disappear- detailed under PRPP synthetase superactivity, to inhibit the
ance of self-mutilation was obtained by chronic stimulation formation of 2,8-dihydroxyadenine. Both in patients with
of the globus pallidus [63]. stones and in those without symptoms, dietary purine res-
triction and high fluid intake are recommended. Alkalini-
zation of the urine is, however, not advised: unlike that of
35.1.10 Adenine Phosphoribosyltransferase uric acid, the solubility of 2,8-dihydroxyadenine does not
Deficiency increase up to pH 9 [64].
Ultimate prognosis depends on renal function at the
Clinical Picture time of diagnosis: late recognition may result in irreversible
The deficiency may become clinically manifest in child- renal insufficiency requiring chronic dialysis, and early
hood [64], even from birth [65], but also remain silent for treatment in prevention of stones. Of note is that kidney
several decades. Symptoms include urinary passage of grav- transplantation has been reported to be followed by recur-
el, small stones and crystals, frequently accompanied by rence of microcrystalline deposits and subsequent loss of
abdominal colic, dysuria, hematuria and urinary tract in- graft function [69].
fection. Some patients may even present with acute anuric
renal failure [66]. The urinary precipitates are composed
of 2,8-dihydroxyadenine, radiotranslucent, and undistin- 35.1.11 Deoxyguanosine Kinase Deficiency
guishable from uric acid stones by routine chemical test-
ing. In several patients with the hepatocerebral form of mito-
chondrial DNA depletion syndrome (7 also Chap. 15),
Metabolic Derangement characterised by early progressive liver failure, neurol-
The deficiency results in suppression of the salvage of ade- ogical abnormalities, hypoglycemia, and increased lactate,
nine (. Fig. 35.1), provided by food and by the polyamine a deficiency of mitochondrial deoxyguanosine kinase
35.1 · Inborn Errors of Purine Metabolism
443 35

was identified [70]. This enzyme phosphorylates the de-

oxycounterpart of guanosine (. Fig. 35.1) into deoxyGMP,
and plays an essential role in the supply of precursors
of mitochondrial DNA, particularly in liver and brain
that lack a cytosolic form of the enzyme. A single nucleo-
tide deletion in the mitochondrial deoxyguanosine kinase
gene segregated with the disease in 19 patients in 3 kin-
dreds [70]. Since then, othere mutations have been iden-
tified.
 444 Chapter 35 · Disorders of Purine and Pyrimidine Metabolism

Pyrimidine Metabolism
Similarly to that of the purine nucleotides, the metabo- 4 The catabolic pathway starts from CMP, UMP
lism of the pyrimidine nucleotides can be divided into and TMP, and yields β-alanine and β-aminoiso-
three pathways: butyrate which are converted into intermediates
4 The biosynthetic pathway starts with the formation of the citric acid cycle.
of carbamoylphosphate by cytosolic carbamoyl- 4 The salvage pathway, composed of kinases,
phosphate synthetase (CPS II), which is different converts the pyrimidine nucleosides, cytidine,
from the mitochondrial CPS I which catalyzes the uridine, and thymidine, into the corresponding
first step of ureogenesis (. Fig. 20.1). This is fol- nucleotides, CMP, UMP, and TMP.
lowed by the synthesis of UMP, and hence of CMP
and TMP.

VIII

. Fig. 35.3. Pathways of pyrimidine metabolism. CMP, cytidine midine (cytosolic) 5’-nucleotidase; 5, cytidine kinase; 6, uridine
monophosphate; glu-NH2, glutamine; OMP, orotidine monophos- kinase; 7, thymidine kinase; 8, thymidine phosphorylase; 9, dihy-
phate; PRPP, phosphoribosylpyrophosphate; TMP, thymidine dropyrimidine dehydrogenase; 10, dihydropyrimidinase; 11, ure-
monophosphate; UMP, uridine monophosphate. 1, carbamoyl- idopropionase. Enzyme deficiencies are indicated by solid bars
phosphate synthetase; 2, orotate phosphoribosyltransferase; across the arrows
3, orotidine decarboxylase (2 and 3 form UMP synthase); 4, pyri-
35.2 · Inborn Errors of Pyrimidine Metabolism
445 35
35.2 Inborn Errors crystalluria is noted, particularly upon dehydration. Enzy-
of Pyrimidine Metabolism matic diagnosis can be performed on red blood cells. In all
patients reported hitherto, except one, both OPRT and
Inborn errors of pyrimidine metabolism comprise a defect ODC activities were deficient. This defect is termed type I.
of the synthesis of pyrimidine nucleotides (UMP synthase In a single patient, referred to as type II, only the activity of
deficiency), and three inborn errors of pyrimidine catabo- ODC was initially deficient, although that of OPRT also
lism: the deficiencies of dihydropyrimidine dehydrogenase subsequently decreased [72].
(DPD) dihydropyrimidinase (DHP), and pyrimidine 5c-nu-
cleotidase. More recently, superactivity of cytosolic 5c-nu- Treatment and Prognosis
cleotidase, a fourth defect of pyrimidine catabolism, urei- The enzyme defect can be by-passed by the administration
dopropionase deficiency, and deficiencies of thymidine of uridine, which is converted into UMP by uridine kinase
phosphorylase and thymidine kinase, which cause mito- (. Fig. 35.3). An initial dose of 100-150 mg/kg, divided over
chondrial diseases (7 also Chap. 15), have been reported. the day, induces prompt hematologic response and accel-
eration of growth. Further dosage should be adapted to
obtain the lowest possible output of orotic acid. In some
35.2.1 UMP Synthase Deficiency cases normal psychomotor development was achieved, but
(Hereditary Orotic Aciduria) not in others, possibly owing to delayed onset of therapy.

Clinical Presentation
Megaloblastic anemia, which appears a few weeks or months 35.2.2 Dihydropyrimidine Dehydrogenase
after birth, is usually the first manifestation [71, 72]. Periph- Deficiency
eral blood smears often show anisocytosis, poikilocytosis,
and moderate hypochromia. Bone marrow examination Clinical Picture
reveals erythroid hyperplasia and numerous megaloblastic Two forms occur. The first is found in children, most of
erythroid precursors. Characteristically, the anemia does whom display epilepsy, motor and mental retardation, often
not respond to iron, folic acid or vitamin B12. Unrecognized, accompanied by generalized hypertonia, hyperreflexia,
the disorder leads to failure to thrive and to retardation of growth delay, dysmorphic features including microcephaly,
growth and psychomotor development. and autistic features [75, 76]. In these patients, the defi-
ciency of dihydropyrimidine dehydrogenase (DPD) is com-
Metabolic Derangement plete or near-complete. Nevertheless, the severity of the
Uridine monophosphate (UMP) synthase is a bifunctional disorder is highly variable and even asymptomatic cases
enzyme of the de novo synthesis of pyrimidines (. Fig. 35.3). have been identified. The second clinical picture is found in
A first reaction, orotate phosphoribosyltransferase (OPRT), adults who receive the pyrimidine analog, 5-fluorouracil, a
converts orotic acid into OMP, and a second, orotidine de- classic treatment of various cancers including breast, ovary
carboxylase (ODC), decarboxylates OMP into UMP. The or colon [77, 78]. It is characterised by severe toxicity, man-
defect provokes a massive overproduction of orotic acid and ifested by profound neutropenia, stomatitis, diarrhea and
a deficiency of pyrimidine nucleotides [72]. The overpro- neurologic symptoms, including ataxia, paralysis and stu-
duction is attributed to the ensuing decrease of the feedback por. In these patients, DPD deficiency is as a rule partial,
inhibition exerted by the pyrimidine nucleotides on the first and only revealed by 5-fluorouracil therapy.
enzyme of their de novo synthesis, cytosolic carbamoyl
phosphate synthetase II (. Fig. 35.3). The deficiency of py- Metabolic Derangement
rimidine nucleotides leads to impairment of cell division, The deficiency of DPD, which catalyzes the catabolism of
which results in megaloblastic anemia and in retardation uracil and thymine into dihydrouracil and dihydrothymine,
of growth and development. respectively (. Fig. 35.3), leads to the accumulation of the
former compounds [75]. Why a profound DPD deficiency
Genetics becomes manifest in some pediatric patients, but not in oth-
Hereditary orotic aciduria is inherited as an autosomal re- ers, is not known. How the defect leads to neurological
cessive trait. The genetic lesion results in synthesis of an symptoms also remains elusive, but reduction of the con-
enzyme with reduced stability [73]. Three point mutations centration of E-alanine, a neurotransmitter, may play a role.
have been identified in two Japanese families [74]. The marked potentiation of the action of the anticancer
drug 5-fluorouracil, and henceforth of its toxicity, is ex-
Diagnostic Tests plained by a block of the catabolism, via DPD, of this pyri-
Urinary analysis reveals a massive over excretion of orotic midine analog.
acid, reaching, in infants, 200- to 1000-fold the normal
adult value of 1–1.5 mg per 24 h. Occasionally, orotic acid
 446 Chapter 35 · Disorders of Purine and Pyrimidine Metabolism

Genetics are excreted in urine [76]. There is also a moderate elevation

The infantile form of DPD deficiency is inherited as an au- of uracil and thymine excretion. As in DPD deficiency, the
tosomal recessive trait. The DPD gene is localized on chro- reasons for the appearance and the mechanisms of the
mosome 1, and about 40 mutations have been identified. symptoms remain unexplained, and reduced concentra-
Most frequent is a splice site mutation (IVS14+1G>A), tions of the neurotransmitter E-alanine may play a role.
which results in skipping of a complete exon [76, 78, 79]. Increased sensitivity to 5-fluorouracil, leading to severe
Strikingly, patients who carry the same mutation may dis- toxicity has also been reported [82].
play widely variable clinical symptoms. In the adult form of
DPD deficiency, characterized by 5c-fluorouracil toxicity, Genetics
approximately 25% of patients are heterozygotes for the The defect is inherited as an autosomal recessive trait. Stud-
IVS14+1G>A mutation [78]. ies of the DHP gene, localized on chromosome 8, have led
to the identification of one frameshift and five missense
Diagnostic Tests mutations in one symptomatic and five asymptomatic indi-
Patients excrete high amounts of uracil (56–683 mmol/mol viduals [83]. Enzyme expression showed no significant dif-
creatinine, as compared to 3–33 in control urine) and of ference in residual activity between the mutations of the
thymine (7–439 mmol/mol creatinine, as compared to symptomatic and the asymptomatic individuals.
0–4 in control urine). Elevations of uracil and thymine in
plasma and cerebrospinal fluid are much less prominent Diagnostic Tests
[76]. Excretion of both compounds may also be less elevat- Elevation of urinary dihydrouracil and dihydrothymine can
ed in patients with high residual DPD activity. The pyri- be detected by the techniques used for measurement of
midine catabolites can be detected by HPLC, GC-MS, and uracil and thymine in DPD deficiency. Enzyme assay re-
VIII analysis of amino acids in urine before and after acid hy- quires liver biopsy, since more accessible tissues do not pos-
drolysis [80]. sess DHP activity [81].
The enzyme defect can be demonstrated in the patients’
fibroblasts, liver and blood cells, with the exception of eryth- Treatment and Prognosis
rocytes [75, 76, 78]. In the pediatric patients, DPD deficien- There is no therapy and prognosis seems unpredictable.
cy is complete or near-complete; in the adult cancer patients The first reported patient recovered completely and appar-
experiencing acute 5-fluorouracil toxicity it is partial, with ently displays normal physical and mental development
residual enzyme activities ranging from 3 to 30%. [81]. In contrast, another patient had a progressive neuro-
degenerative clinical course [84].
Treatment and Prognosis
No treatment is available for pediatric patients. Symptoms
usually remain the same, but death in early infancy of a 35.2.4 Ureidopropionase Deficiency
more severely affected child has been reported. In the adult
cancer patients, discontinuation of 5-fluorouracil results in In a female infant of consanguineous parents, presenting
slow resolution of the toxic symptoms [77, 78]. with muscle hypotonia, dystonic movements and severe de-
velopmental delay, in vitro H-NMR spectroscopy of urine
revealed elevated ureidopropionic acid (also called N-car-
35.2.3 Dihydropyrimidinase Deficiency bamyl-E-alanine) and ureidoisobutyric acid (also called N-
carbamyl-E-aminoisobutyric acid) [85]. These findings led
Clinical Picture to the identification of ureidopropionase deficiency (also
This disorder was first reported in a single male baby of termed E-alanine synthase) in the liver [86].
consanguineous parents, presenting with convulsions and
metabolic acidosis [81]. Additional patients have been di-
agnosed since then [76]. As in DPD deficiency, the clinical 35.2.5 Pyrimidine 5’-Nucleotidase
picture varies from severe psychomotor retardation with Deficiency
epilepsy, dysmorphic features or microcephaly, to com-
pletely asymptomatic. This defect, restricted to erythrocytes, leads to accumula-
tion of pyrimidine nucleotides resulting in basophilic stip-
Metabolic Derangement pling and chronic hemolytic anemia [87]. The mechanism
Dihydropyrimidinase (DHP) catalyzes the cleavage of di- by which the increased pyrimidine nucleotides cause hemo-
hydrouracil and dihydrothymine into, repectively, E-urei- lysis remains unknown.
dopropionate and E-ureidoisobutyrate (. Fig. 35.3). Conse-
quently, considerable quantities of dihydrouracil and dihy-
drothymine, which are normally found in small amounts,
References
447 35
35.2.6 Cytosolic 5’-Nucleotidase 4. Kranen S, Keough D, Gordon RB, Emmerson BT (1985) Xanthine-
Superactivity containing calculi during allopurinol therapy. J Urol 133:658-659
5. Jaeken J, Van den Berghe G (1984) An infantile autistic syndrome
characterised by the presence of succinylpurines in body fluids.
Four unrelated children have been described with a syn- Lancet 2:1058-1061
drome including developmental delay, growth retardation, 6. Jaeken J, Wadman SK, Duran M et al (1988) Adenylosuccinase defi-
seizures, ataxia, recurrent infections, autistic features and ciency : an inborn error of purine nucleotide synthesis. Eur J Pediatr
hypouricosuria [88]. Studies in the patients’ fibroblasts 148:126-131
7. Valik D, Miner PT, Jones JD (1997) First U.S. case of adenylosuccinate
showed 6- to 20-fold elevations of the activity of cytosolic
lyase deficiency with severe hypotonia. Pediatr Neurol 16:252-255
5c-nucleotidase, measured either with a pyrimidine (UMP) 8. Van den Bergh FAJTM, Bosschaart AN, Hageman G et al (1998)
or a purine (AMP) as substrate. Based on the possibility that Adenylosuccinase deficiency with neonatal onset severe epileptic
this increased catabolism might cause a deficiency of pyri- seizures and sudden death. Neuropediatrics 29:51-53
midine nucleotides, the patients were treated with uridine 9. Van den Berghe G, Vincent MF, Jaeken J (1997) Inborn errors of
the purine nucleotide cycle: adenylosuccinase deficiency. J Inherit
at the dose of 1 g/kg per day. Remarkable developmental
Metab Dis 20:193-202
improvement, and a decrease in frequency of seizures and 10. De Volder AG, Jaeken J, Van den Berghe G et al (1988) Regional
infections were recorded. brain glucose utilization in adenylosuccinase-deficient patients
measured by positron emission tomography. Pediatr Res 24:238-
242
35.2.7 Thymidine Phosphorylase 11. Stone RL, Aimi J, Barshop BA et al (1992) A mutation in adenylosuc-
cinate lyase associated with mental retardation and autistic fea-
Deficiency tures. Nat Genet 1:59-63
12. Marie S, Cuppens H, Heuterspreute M et al (1999) Mutation analysis
Patients with mitochondrial neurogastrointestinal enceph- in adenylosuccinate lyase deficiency. Eight novel mutations in
alomyopathy (MNGIE), an autosomal recessive disease the re-evaluated full ADSL coding sequence. Hum Mutat 13:197-
202
associated with multiple deletions of skeletal muscle mito-
13. Kmoch S, Hartmannova H, Stiburkova B et al (2000) Human adeny-
chondrial DNA (7 also Chap. 15), have been shown deficient losuccinate lyase (ADSL), cloning and characterization of full-length
in thymidine phosphorylase, owing to a variety of muta- cDNA and its isoform, gene structure and molecular basis for ADSL
tions [89]. The enzyme deficiency results in marked accu- deficiency in six patients. Hum Mol Genet 9:1501-1513
mulation of thymidine, which most likely provokes imbal- 14. Marie S, Race V, Nassogne MC et al (2002) Mutation of a nuclear
respiratory factor 2 binding site in the 5cuntranslated region of the
ance of the mitochondrial nucleotides, and hence compro-
ADSL gene in three patients with adenylosuccinate lyase deficien-
mises the replication of mitochondrial DNA. cy. Am J Hum Genet 71:14-21
15. Laikind PK, Seegmiller JE, Gruber HE (1986) Detection of 5c-phos-
phoribosyl-4-(N-succinylcarboxamide)-5-aminoimidazole in urine
35.2.8 Thymidine Kinase Deficiency by use of the Bratton-Marshall reaction : identification of patients
deficient in adenylosuccinate lyase activity. Anal Biochem 156:81-
90
In four independent patients with very severe, isolated my- 16. Sebesta I, Shobowale M, Krijt J, Simmonds HA (1995) Screening
opathy, and depletion of muscular mitochondrial DNA tests for adenylosuccinase deficiency. Screening 4:117-124
(7 also Chap. 15), two mutations of the gene encoding thy- 17. Marie S, Flipsen JWAM, Duran M et al (2000) Prenatal diagnosis in
midine kinase-2, the mitochondrial form of the thymidine adenylosuccinate lyase deficiency. Prenat Diagn 20:33-36
18. Salerno C, D’Eufemia P, Finocchiaro R et al (1999) Effect of D-ribose
salvage enzyme, have been identified [90]. As in the defi-
on purine synthesis and neurological symptoms in a patient with
ciencies of deoxyguanosine kinase and thymidine phospho- adenylosuccinase deficiency. Biochim Biophys Acta 1453:135-140
rylase, the defect likely produces imbalance of the mito- 19. Salerno C, Crifo C, Curatolo P, Ciardo F (2000) Effect of uridine ad-
chondrial nucleotides which disturbs the replication of ministration to a patient with adenylosuccinate lyase deficiency.
mitochondrial DNA. Adv Exp Biol Med 486:75-78
20. Marie S, Heron B, Bitoun P et al (2004) AICA-Ribosiduria: a novel,
neurologically devastating inborn error of purine biosynthesis
caused by mutation of ATIC. Am J Hum Genet 74:1276-1281
References 21. Fishbein WN, Armbrustmacher VW, Griffin JL (1978) Myoadenylate
deaminase deficiency : a new disease of muscle. Science 200:545-
1. Sperling O, Boer P, Persky-Brosh S et al (1972) Altered kinetic prop- 548
erty of erythrocyte phosphoribosylpyrophosphate synthetase in 22. Shumate JB, Katnik R, Ruiz M et al (1979) Myoadenylate deaminase
excessive purine production. Rev Eur Etud Clin Biol 17:703-706 deficiency. Muscle Nerve 2:213-216
2. Becker MA, Puig JG, Mateos FA et al (1988) Inherited superactivity 23. Mercelis R, Martin JJ, de Barsy T, Van den Berghe G (1987) Myoad-
of phosphoribosylpyrophosphate synthetase: association of uric enylate deaminase deficiency : absence of correlation with exercise
acid overproduction and sensorineural deafness. Am J Med 85:383- intolerance in 452 muscle biopsies. J Neurol 234:385-389
390 24. Van den Berghe G, Bontemps F, Vincent MF, Van den Bergh F (1992)
3. Becker MA, Smith PR, Taylor W et al (1995) The genetic and func- The purine nucleotide cycle and its molecular defects. Progr Neu-
tional basis of purine nucleotide feedback-resistant phosphoribo- robiol 39:547-561
sylpyrophosphate synthetase superactivity. J Clin Invest 96:2133- 25. Hers HG, Van den Berghe G (1979) Enzyme defect in primary gout.
2141 Lancet 1:585-586
 448 Chapter 35 · Disorders of Purine and Pyrimidine Metabolism

26. Ogasawara N, Goto H, Yamada Y et al (1987) Deficiency of AMP 47. Dent CE, Philpot GR (1954) Xanthinuria, an inborn error (or devia-
deaminase in erythrocytes. Hum Genet 75:15-18 tion) of metabolism. Lancet 1:182-185
27. Morisaki T, Gross M, Morisaki H et al (1992) Molecular basis of AMP 48. Wadman SK, Duran M, Beemer FA et al (1983) Absence of hepatic
deaminase deficiency in skeletal muscle. Proc Natl Acad Sci USA molybdenum cofactor : an inborn error of metabolism leading to
89:6457-6461 a combined deficiency of sulphite oxidase and xanthine dehydro-
28. Loh E, Rebbeck TR, Mahoney PD et al (1999) Common variant in genase. J Inherit Metab Dis 6[Suppl 1]:78-83
AMPD1 gene predicts improved outcome in patients with heart 49. Shih VE, Abroms IF, Johnson JL et al (1977) Sulfite oxidase deficiency.
failure. Circulation 23:1422-1425 Biochemical and clinical investigations of a hereditary metabolic
29. Sabina RL, Fishbein WN, Pezeshkpour G et al (1992) Molecular disorder in sulfur metabolism. N Engl J Med 297:1022-1028
analysis of the myoadenylate deaminase deficiencies. Neurology 50. Ichida K, Amaya Y, Kamatani N et al (1997) Identification of two
42:170-179 mutations in human xanthine dehydrogenase gene responsible for
30. Zöllner N, Reiter S, Gross M et al (1986) Myoadenylate deaminase classical type I xanthinuria. J Clin Invest 99:2391-2397
deficiency: successful symptomatic therapy by high dose oral ad- 51. Yamamoto T, Moriwaki Y, Takahashi S et al (2003) Identification of a
ministration of ribose. Klin Wochenschr 64:1281-1290 new point mutation in the human molybdenum cofactor sulferase
31. Giblett ER, Anderson JE, Cohen F et al (1972) Adenosine-deaminase gene that is responsible for xanthinuria type II. Metabolism
deficiency in two patients with severely impaired cellular immu- 52:1501-1504
nity. Lancet 2:1067-1069 52. Reiss J, Johnson JL (2003) Mutations in the molybdenum cofactor
32. Hershfield MS, Arredondo-Vega FX, Santisteban I (1997) Clinical biosynthetic genes MOCS1, MOCS2, and GEPH. Hum Mutat 21:569-
expression, genetics and therapy of adenosine deaminase (ADA) 576
deficiency. J Inherit Metab Dis 20:179-185 53. Lesch M, Nyhan WL (1964) A familial disorder of uric acid metabo-
33. Bollinger ME, Arredondo-Vega FX, Santisteban I et al (1996) Brief lism and central nervous system dysfuntion. Am J Med 36:561-
report: hepatic dysfunction as a complication of adenosine deami- 570
nase deficiency. N Engl J Med 334:1367-1371 54. Kelley WN, Greene ML, Rosenbloom FM et al (1969) Hypoxanthine-
34. Thompson LF , Vaughn JG, Laurent AB et al (2003) Mechanisms of guanine phosphoribosyltransferase deficiency in gout. Ann Intern
apoptosis in developing thymocytes as revealed by adenosine Med 70:155-206
VIII deaminase-deficient fetal thymic organ cultures. Biochem Pharma- 55. Ernst M, Zametkin AJ, Matochik JA et al (1996) Presynaptic
col 66:1595-1599 dopaminergic deficits in Lesch-Nyhan disease. N Engl J Med 334:
35. Hirschhorn R, Yang DR, Puck JM et al (1996). Spontaneous in vivo 1568-1572
reversion to normal of an inherited mutation in a patient with 56. Jinnah HA, De Gregorio L, Harris JC et al (2000) The spectrum of
adenosine deaminase deficiency. Nat Genet 13:290-295 inherited mutations causing HPRT deficiency: 75 new cases and a
36. Markert ML, Hershfield MS, Schiff RI, Buckley RH (1987) Adenosine review of 196 previously reported cases. Mutat Res 463:309-326
deaminase and purine nucleoside phosphorylase deficiencies: 57. Alford RL, Redman JB, O’Brien WE, Caskey CT (1995) Lesch-Nyhan
evaluation of therapeutic interventions in eight patients. J Clin Im- syndrome: carrier and prenatal diagnosis. Prenat Diagn 15:329-
munol 7:389-399 338
37. Hershfield MS (1995) PEG-ADA replacement therapy for adenosine 58. Kaufman JM, Greene ML, Seegmiller JE (1968) Urine uric acid to
deaminase deficiency: an update after 8.5 years. Clin Immunol creatinine ratio - a screening test for inherited disorders of purine
Immunopathol 76:S228-S232 metabolism. Phosphoribosyltransferase (PRT) deficiency in X-
38. Blaese RM, Culver KW, Miller AD et al (1995) T-lymphocyte-directed linked cerebral palsy and in a variant of gout. J Pediatr 73:583-592
gene therapy for ADA-SCID: initial trial results after 4 years. Science 59. Seegmiller JE, Rosenbloom FM, Kelley WN (1967) Enzyme defect
270:475-480 associated with a sex-linked human neurological disorder and
39. Muul LM, Tuschong LM, Soenen SL et al (2003) Persistence and ex- excessive purine synthesis. Science 155:1682-1684
pression of the adenosine deaminase gene for 12 years and im- 60. Page T, Bakay B, Nissinen E, Nyhan WL (1981) Hypoxanthine-gua-
mune reaction to gene transfer components: long-term results of nine phosphoribosyltransferase variants: correlation of clinical
the first clinical gene therapy trial. Blood 101:2563-2569 phenotype with enzyme activity. J Inherit Metab Dis 4:203-206
40. Aiuti A, Slavin S, Aker M et al (2002) Correction of ADA-SCID by stem 61. Watts RWE, McKeran RO, Brown E et al (1974) Clinical and biochem-
cell gene therapy combined with nonmyeloablative conditioning ical studies on treatment of Lesch-Nyhan syndrome. Arch Dis Child
Science 296:2410-2413 49:693-702
41. Cavazzana-Calvo M, Lagresle C, Hacein-Bey-Abina S, Fisher A (2005) 62. Nyhan WL, Parkman R, Page T et al (1986) Bone marrow transplan-
Gene therapy for severe combined immunodeficiency. Annu Rev tation in Lesch-Nyhan disease. Adv Exp Med Biol 195A:167-170
Med 56:585-602 63. Taira T, Kobayashi T, Hori T (2003) Disappearance of self-mutilating
42. Valentine WN, Paglia DE, Tartaglia AP, Gilsanz F (1977) Hereditary behavior in a patient with Lesch-Nyhan syndrome after bilateral
hemolytic anemia with increased red cell adenosine deaminase chronic stimulation of the globus pallidus internus. Case report.
(45- to 70-fold) and decreased adenosine triphosphate. Science J Neurosurg 98:414-416
195:783-785 64. Cartier P, Hamet M (1974) Une nouvelle maladie métabolique:
43. Giblett ER, Ammann AJ, Wara DW et al (1975) Nucleoside phospho- le déficit complet en adénine-phosphoribosyltransférase avec li-
rylase deficiency in a child with severely defective T-cell immunity thiase de 2,8-dihydroxyadénine. C R Acad Sci Paris 279[série D]:883-
and normal B-cell immunity. Lancet 1:1010-1013 886
44. Markert ML (1991) Purine nucleoside phosphorylase deficiency. 65. Van Acker KJ, Simmonds HA, Potter C, Cameron JS (1977) Complete
Immunodefic Rev 3:45-81 deficiency of adenine phosphoribosyltransferase. Report of a fam-
45. Markert ML, Finkel BD, McLaughlin TM et al (1997) Mutations in ily. N Engl J Med 297:127-132
purine nucleoside phosphorylase deficiency. Hum Mutat 9:118- 66. Greenwood MC, Dillon MJ, Simmonds HA et al (1982) Renal failure
121 due to 2,8-dihydroxyadenine urolithiasis. Eur J Pediatr 138:346-
46. Carpenter PA, Ziegler JB, Vowels MR (1996) Late diagnosis and cor- 349
rection of purine nucleoside phosphorylase deficiency with alloge- 67. Hidaka Y, Tarlé SA, Fujimori S et al (1988) Human adenine phos-
neic bone marrow transplantation. Bone Marrow Transplant phoribosyltransferase deficiency. Demonstration of a single mu-
17:121-124 tant allele common to the Japanese. J Clin Invest 81:945-950
References
449 35

68. Sahota A, Chen J, Stambrook PJ, Tischfield JA (1991) Mutational 89. Nishino I, Spinazzola A, Papadimitriou A et al (2000) MNGIE: an
basis of adenine phosphoribosyltransferase deficiency. Adv Exp autosomal recessive disorder due to thymidine phosphorylase
Med Biol 309B:73-76 mutations. Ann Neurol 47:792-800
69. Eller P, Rosenkranz AR, Mark W et al (2004) Four consecutive renal 90. Saada A, Shaag A, Mandel H et al (2001) Mutant mitochondrial thy-
transplantations in a patient with adenine phosphoribosyltrans- midine kinase in mitochondrial DNA depletion myopathy. Nat
ferase deficiency. Clin Nephrol 61:217-221 Genet 29:342-344
70. Mandel H, Szargel R, Labay V et al (2001) The deoxyguanosine ki-
nase gene is mutated in individuals with depleted hepatocerebral
mitochondrial DNA. Nat Genet 29:337-341
71. Huguley CM, Bain JA, Rivers SL, Scoggins RB (1959) Refractory
megaloblastic anemia associated with excretion of orotic acid.
Blood 14:615-634
72. Smith LH (1973) Pyrimidine metabolism in man. N Engl J Med
288:764-771
73. Perry ME, Jones ME (1989) Orotic aciduria fibroblasts express a
labile form of UMP synthase. J Biol Chem 264:15522-15528
74. Suchi M, Mizuno H, Kawai Y et al (1997) Molecular cloning of the
human UMP synthase gene and characterization of point muta-
tions in two hereditary orotic aciduria families. Am J Hum Genet
60:525-539
75. Berger R, Stoker-de Vries SA, Wadman SK et al (1984) Dihydropyri-
midine dehydrogenase deficiency leading to thymine-uraciluria.
An inborn error of pyrimidine metabolism. Clin Chim Acta 141:227-
234
76. Van Gennip AH, Abeling NGGM, Vreken P, van Kuilenburg ABP
(1997) Inborn errors of pyrimidine degradation: clinical, biochemi-
cal and molecular aspects. J Inherit Metab Dis 20:203-213
77. Tuchman M, Stoeckeler JS, Kiang DT et al (1985) Familial pyrimi-
dinemia and pyrimidinuria associated with severe fluorouracil tox-
icity. N Engl J Med 313:245-249
78. Van Kuilenburg ABP (2004) Dihydropyrimidine dehydrogenase and
the efficacy and toxicity of 5-fluorouracil. Eur J Cancer 40:939-950
79. Van Kuilenburg AB, Vreken P, Abeling NG et al (1999) Genotype and
phenotype in patients with dihydropyrimidine dehydrogenase de-
ficiency. Hum Genet 104:1-9
80. Van Gennip AH, Driedijk PC, Elzinga A, Abeling NGGM (1992)
Screening for defects of dihydropyrimidine degradation by analy-
sis of amino acids in urine before and after acid hydrolysis. J In-
herit Metab Dis 15:413-415
81. Duran M, Rovers P, de Bree PK et al (1991) Dihydropyrimidinuria:
a new inborn error of pyrimidine metabolism. J Inherit Metab Dis
14:367-370
82. Van Kuilenburg AB, Meinsma R, Zonnenberg BA et al (2003) Dihy-
dropyrimidinase deficiency and severe 5-fluorouracil toxicity. Clin
Cancer Res 9:4363-4367
83. Hamajima N, Kouwaki M, Vreken P et al (1998) Dihydropyrimidinase
deficiency: structural organization, chromosomal localization, and
mutation analysis of the human dihydropyrimidinase gene. Am J
Hum Genet 63:717-726
84. Putman CW, Rotteveel JJ, Wevers RA et al (1997) Dihydropyrimidi-
nase deficiency: a progressive neurological disorder ? Neuropedi-
atrics 28:106-110
85. Assmann B, Göhlich-Ratmann G, Bräutigam C et al (1998) Presump-
tive ureidopropionase deficiency as a new defect in pyrimidine
catabolism found with in vitro H-NMR spectroscopy. J Inherit Me-
tab Dis 21[Suppl 2]:1
86. Van Kuilenburg AB, Meinsma R, Beke E et al (2004) Beta-ureidopro-
pionase deficiency: an inborn error or pyrimidine degradation as-
sociated with neurological abnormalities. Hum Mol Genet 13:2793-
2801
87. Valentine WN, Fink K, Paglia DE et al (1974) Hereditary hemolytic
anemia with human erythrocyte pyrimidine 5c-nucleotidase defi-
ciency. J Clin Invest 54:866-879
88. Page T, Yu A, Fontanesi J, Nyhan WL (1997) Developmental disorder
associated with increased cellular nucleotidase activity. Proc Natl
Acad Sci USA 94:11601-11606