Multiple Acyl-CoA Dehydrogenase Deficiency
MAD deficiency

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Description from OMIM

Glutaric aciduria II (GA II) is an autosomal recessively inherited disorder of fatty acid, amino acid, and choline metabolism. It differs from GA I (231670) in that multiple acyl-CoA dehydrogenase deficiencies result in large excretion not only of glutaric acid, but also of lactic, ethylmalonic, butyric, isobutyric, 2-methyl-butyric, and isovaleric acids. GA II results from deficiency of any 1 of 3 molecules: the alpha (ETFA) and beta (ETFB) subunits of electron transfer flavoprotein, and electron transfer flavoprotein dehydrogenase (ETFDH). The clinical picture of GA II due to the different defects appears to be indistinguishable; each defect can lead to a range of mild or severe cases, depending presumably on the location and nature of the intragenic lesion, i.e., mutation, in each case (Goodman, 1993; Olsen et al., 2003). The heterogeneous clinical features of patients with MADD fall into 3 classes: a neonatal-onset form with congenital anomalies (type I), a neonatal-onset form without congenital anomalies (type II), and a late-onset form (type III). The neonatal-onset forms are usually fatal and are characterized by severe nonketotic hypoglycemia, metabolic acidosis, multisystem involvement, and excretion of large amounts of fatty acid- and amino acid-derived metabolites. Symptoms and age at presentation of late-onset MADD are highly variable and characterized by recurrent episodes of lethargy, vomiting, hypoglycemia, metabolic acidosis, and hepatomegaly often preceded by metabolic stress. Muscle involvement in the form of pain, weakness, and lipid storage myopathy also occurs. The organic aciduria in patients with the late-onset form of MADD is often intermittent and only evident during periods of illness or catabolic stress (summary by Frerman and Goodman, 2001). Importantly, riboflavin treatment has been shown to ameliorate the symptoms and metabolic profiles in many MADD patients, particularly those with type III, the late-onset and mildest form (Liang et al., 2009).



Prevalence of clinical parameters (%)







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List of symptoms



Symptom/sign Organ system Percent affected Pubmed id Added on(yyyy-mm-dd) Edit/add reference
Myalgia skeletal 100 % 20370797 2012-07-26
Increased blood CK circulatory 100 % 20370797 2012-07-26
Muscle weakness skeletal 89 % 20370797 2012-07-26
Steatosis digestive 75 % 2658591 2011-12-05
Hypotonia nervous 66 % 17977044 2012-07-26
Hypoglycemia circulatory 66 % 17977044 2012-07-26
Ethylmalonic aciduria circulatory 62 % 2658591 2011-11-21
Hypotonia nervous 56 % 2658591 2011-11-21
Hepatomegaly multi 44 % 2658591 2011-11-21
Gliosis nervous 44 % 2658591 2011-11-21
Dysphagia nervous 44 % 20370797 2012-07-26
Increased blood transaminase digestive 33 % 17977044 2012-07-26
Hepatomegaly digestive 33 % 17977044 2012-07-26
Hyperammonemia circulatory 33 % 17977044 2012-07-26
Failure to thrive multi 33 % 17977044 2012-07-26
Cardiac arrhythmia circulatory 33 % 17977044 2012-07-26
Hypothermia multi 33 % 17977044 2012-07-26
Developmental delay multi 33 % 17977044 2012-07-26
Seizures nervous 33 % 17977044 2012-07-26
Fatty heart multi 31 % 2658591 2011-11-21
Hypertelorism multi 31 % 2658591 2011-11-21
Macrocephaly nervous 25 % 2658591 2011-12-05
Hepatopathy digestive 22 % 20370797 2012-07-26
Heterotopia nervous 19 % 2658591 2011-12-05
Micrognathia multi 13 % 2658591 2011-11-21
High arched palate digestive 13 % 2658591 2011-12-11
Congestive heart failure circulatory 11 % 20370797 2012-07-26
Cardiac arrhythmia circulatory 11 % 20370797 2012-07-26
Seizures nervous 11 % 20370797 2012-07-26
Hypoglycemia circulatory 11 % 20370797 2012-07-26
Steatosis digestive 11 % 20370797 2012-07-26



List of references:


High frequency of ETFDH c.250G>A mutation in Taiwanese patients with late-onset lipid storage myopathy.
M-Y Lan, M-H Fu, Y-F Liu, C-C Huang, Y-Y Chang, J-S Liu, C-H Peng, S-S Chen,

Lipid storage myopathies (LSMs) are characterized pathologically by the accumulation of lipid droplets in muscle fibers due to impaired cellular lipid metabolism. The purpose of this study was to determine etiologies and genetic mutations associated with LSMs in ethnic Han Taiwanese. The usefulness of the blood acylcarnitine (AC) profile for diagnosing LSMs in adult patients was also investigated. Nine patients were diagnosed with late-onset LSMs following a review of muscle biopsies and medical records and were recruited retrospectively. Genetic studies were performed to detect mutations in the SLC22A5 for primary carnitine deficiency, PNPLA2 for neutral lipid storage disease with myopathy, ABHD5 for neutral lipid storage disease with ichthyosis, ETFDH for multiple acyl-CoA dehydrogenation deficiency (MADD), and CPT2 for carnitine palmitoyltransferase II deficiency. Blood AC levels were measured by tandem mass spectrometry. The mutation c.250G>A in ETFDH was detected in seven (78%) patients, six of whom were homozygous for the variant. Patients with ETFDH mutations had elevated blood levels of ACs ranging from C8 to C16 species, a pattern consistent with MADD. ETFDH c.250G>A mutation is common in Taiwanese patients with late-onset LSMs. The blood AC profile is a sensitive biochemical marker for diagnosing MADD arising from ETFDH mutations in adults.

Clinical genetics - Dec 2010



Glutaric aciduria type II: review of the phenotype and report of an unusual glomerulopathy.
G N Wilson, J P de Chadarévian, P Kaplan, J P Loehr, F E Frerman, S I Goodman,

A male infant with glutaric aciduria II secondary to electron transfer flavoprotein: ubiquinone oxidoreductase deficiency is compared to previously reported cases of glutaric aciduria II. A common pattern of anomalies in patients with malformations (8/16) includes macrocephaly, large anterior fontanelle, high forehead, flat nasal bridge, telecanthus, and malformed ears. Abnormalities such as hypotonia, cerebral gliosis, heterotopias, hepatomegaly, hepatic periportal necrosis, polycystic kidneys, and genital defects in glutaric aciduria II are reminiscent of those in Zellweger syndrome, whereas elevations of glutaric, ethylmalonic, adipic, and isovaleric acids are quite distinctive. A unique ultrastructural alteration of the glomerular basement membrane was observed in the proposita. This manifestation may represent an early stage in renal cyst formation and provide a diagnostic criterion for glutaric aciduria II when enzyme studies are unavailable.

American journal of medical genetics - Mar 1989



Risk of sudden death and acute life-threatening events in patients with glutaric acidemia type II.
Brad Angle, Barbara K Burton,

Glutaric acidemia type II (GAII) is an inborn error of metabolism caused by defects in electron transport flavoprotein (ETF) or ETF-ubiquinone oxidoreductase (ETF-QO) and typically presents with hypo- or nonketotic hypoglycemia and metabolic acidosis. The most severe forms present in early infancy and are associated with a high mortality rate. The disorder can now be detected by expanded newborn screening using tandem mass spectrometry (MS/MS), providing the opportunity for diagnosis and treatment in asymptomatic infants. We report here three infants who, despite diagnosis and treatment in the neonatal period, experienced either unexpected sudden death or an acute life-threatening event (ALTE) during the first year of life. The possible etiologies of these events and the potential impact of expanded newborn screening on the long-term outcome of GAII are discussed.

Molecular genetics and metabolism - Jan 2008