Maple syrup urine disease

Maple syrup urine disease is a rare, inherited metabolic disorder that affects the body's ability to metabolize amino acids due to a deficiency in the activity of the branched-chain alpha-ketoacid dehydrogenase complex. It particularly affects the metabolism of amino acids leucine, isoleucine, and valine. With MSUD, the body is not able to properly break down these amino acids, therefore leading to the amino acids to build up in urine and become toxic. The condition gets its name from the distinctive sweet odor of affected infants' urine and earwax due to the buildup of these amino acids.

Classification

Maple syrup urine disease can be classified by its pattern of signs and symptoms or by its genetic cause. The most common and severe form of this disease is the classic type, which appears soon after birth, and as long as it remains untreated, gives rise to progressive and unremitting symptoms. Variant forms of the disorder may become apparent only later in infancy or childhood, with typically less severe symptoms that may only appear during times of fasting, stress, or illness, but still involve mental and physical problems if left untreated.
There are five main types of maple syrup urine disease:

Classic maple syrup urine disease
Intermediate maple syrup urine disease
Intermittent maple syrup urine disease
Thiamine-responsive maple syrup urine disease
E3-deficient maple syrup urine disease

These types can be classified based on time of onset, severity of symptoms, and level of BCKAD complex enzyme activity. Generally, the majority of patients will be classified into one of these four categories but some patients affected by maple syrup urine disease do not fit the criteria for the listed sub-divisions and may be categorized into unclassified maple syrup urine disease.

Classic

Classic MSUD is the most common type of MSUD. It also has the earliest onset and is presented with the most severe symptoms. Symptoms can be seen from within 7–10 days of birth. The maple syrup odor to the earwax is apparent around 12 hours after birth. The sweet-smelling urine is presented around a week after birth when protein metabolism has accelerated. Some other signs that may be seen are poor feeding, vomiting, irritability, lethargy, apnea, seizures, acidosis, and encephalopathy.
Infants with classic MSUD will display subtle symptoms within the first 24–48 hours. Subtle symptoms include poor feeding, either bottle or breast, lethargy, and irritability. The infant will then experience increased focal neurologic signs. These neurologic signs include athetosis, hypertonia, spasticity, and opisthotonus that lead to convulsions and coma. If MSUD is left untreated, central neurologic function and respiratory failure will occur and lead to death. Although MSUD can be stabilized, there are still threats of metabolic decompensation and loss of bone mass that can lead to osteoporosis, pancreatitis, and intracranial hypertension. Additional signs and symptoms that can be associated with classic MSUD include intellectual limitation and behavioral issues.

Intermediate

This type is a milder form of MSUD in comparison to classic MSUD. Intermediate MSUD has greater levels of residual enzyme activity than classic MSUD. The majority of children with intermediate MSUD are diagnosed between the ages of 5 months and 7 years. Symptoms associated with classic MSUD also appear in intermediate MSUD. Maple syrup odor to the urine and earwax is observed. Patients with intermediate MSUD may be presented with acidosis and developmental delay.

Intermittent

Contrary to classic and intermediate MSUD, intermittent MSUD individuals will have normal growth and intellectual development. This type of MSUD is typically presented around 1 to 2 years of life. Other symptoms may include ataxia and semicoma. These symptoms may accelerate and worsen rapidly. Symptoms of lethargy and characterized odor of maple syrup will occur when the individual experiences stress, does not eat or develops an infection. The metabolic crisis leading to seizures, coma, and brain damage is still a possibility.

Thiamine-response

Symptoms associated with thiamine-response MSUD are similar to intermediate MSUD. Newborns rarely present with symptoms. This is a distinctive type of MSUD because they respond very well to thiamine therapy. Symptoms may include acidosis and developmental delay.

E3-Deficient

This type of MSUD is diagnosed from the deficiencies of the E3 subunits. Some signs that may seen from E3-deficient MSUD include feeding difficulties, developmental delay, acidosis, encephalopathy, liver failure, and early death. There may be varying level of enzyme activity.

Later onset

The symptoms of MSUD may also present later depending on the severity of the disease. Untreated in older individuals, and during times of metabolic crisis, symptoms of the condition include uncharacteristically inappropriate, extreme or erratic behavior and moods, hallucinations, lack of appetite, weight loss, anemia, diarrhea, vomiting, dehydration, lethargy, oscillating hypertonia and hypotonia, ataxia, seizures, hypoglycaemia, ketoacidosis, opisthotonus, pancreatitis, rapid neurological decline, and coma. Death from cerebral oedema will likely occur if there is no treatment. Additionally, MSUD patients experience an abnormal course of diseases in simple infections that can lead to permanent damage.

Signs and symptoms

Signs and symptoms of MSUD vary between patients and are greatly related to the amount of residual enzyme activity. Some characteristics of MSUD include maple syrup odor to the urine or earwax, neurological disorders, psychological disorders, feeding problems, and metabolic acidosis. If left untreated, it may lead to metabolic crisis. Metabolic crises can be life-threatening and should be treated immediately.

Causes

Mutations in the following genes cause maple syrup urine disease:

BCKDHA
BCKDHB
DBT
DLD

These four genes produce proteins that work together as the branched-chain alpha-keto acid dehydrogenase complex. The complex is essential for breaking down the amino acids leucine, isoleucine, and valine. These are present in some quantity in almost all kinds of food, but in particular, protein-rich foods such as dairy products, meat, fish, soy, gluten, eggs, nuts, whole grains, seeds, avocados, algae, edible seaweed, beans, and pulses. Mutation in any of these genes reduces or eliminates the function of the enzyme complex, preventing the normal breakdown of isoleucine, leucine, and valine. As a result, these amino acids and their by-products build up in the body. Because high levels of these substances are toxic to the brain and other organs, this accumulation leads to the serious medical problems associated with maple syrup urine disease.
This condition has an autosomal recessive inheritance pattern, which means the defective gene is located on an autosome, and two copies of the gene – one from each parent – must be inherited to be affected by the disorder. The parents of a child with an autosomal recessive disorder are carriers of one copy of the defective gene, but are usually unaffected by the disorder.

Pathophysiology

Enzyme deficiency

MSUD is a metabolic disorder caused by a deficiency of the branched-chain alpha-keto acid dehydrogenase complex activity, leading to a buildup of the branched-chain amino acids and their toxic branched-chain alpha-keto acid by-products in the blood and urine. The buildup of these BCAAs will lead to the maple syrup odor in earwax and urine that is associated with MSUD. The BCKAD complex begins by breaking down leucine, isoleucine, and valine through the use of branch-chain aminotransferase into their relevant α-ketoacids. The second step involves the conversion of α-ketoacids into acetoacetate, acetyl-CoA, and succinyl-CoA through oxidative decarboxylation of α-ketoacids. The BCKAD complex consists of four subunits designated E₁α, E₁β, E₂, and E₃. The E₃ subunit is also a component of pyruvate dehydrogenase complex and oxoglutarate dehydrogenase complex. MSUD can result from mutations in any of the genes that code for these enzyme subunits, E₁α, E₁β, E₂, and E₃. Mutations of these enzyme subunits will lead to the BCKAD complex unable to break down leucine, isoleucine, and valine. The levels of these branched-chain amino acids will become elevated and lead to the symptoms associated with MSUD.
This enzymatic dysfunction leads to various types of psychiatric disorders, movement disorders, seizures, and encephalopathy. A recent review article attributes these pathological states are caused by lower concentrations of protein and neurotransmitter synthesis within the central nervous system, as well as toxicity due to the buildup of branched-chain amino acids and branched-chain alpha-keto acid. There are multiple mechanisms theorized for MSUD encephalopathy.

Amino acid transport deficiency and neurotransmitter synthesis impairment

Amino acid transport deficiency and neurotransmitter synthesis impairment are significant concerns in individuals with maple syrup urine disease. Reduced levels of amino acids such as glutamate, phenylalanine, tyrosine, tryptophan, methionine, and alanine in the central nervous system have been shown to affect learning, memory, emotional behavior, ADHD, OCD, and movement disorders
In a normal physiological state, large neutral amino acids are transferred from the blood to the brain via the large amino acid transporter at the blood-brain barrier. However, increased plasma levels and higher affinity of leucine may saturate LAT1, thereby competitively preventing the transportation of other amino acids, resulting in lower concentrations within the brain. Amino acids such as isoleucine, valine, threonine, methionine, glutamine, tyrosine, phenylalanine, tryptophan, and histidine are particularly affected. Methionine, a precursor for S-adenosylmethionine, is essential for one-carbon metabolism in the brain, while other LAT1-transported amino acids are involved in the synthesis of neurotransmitters, including histamine, serotonin, dopamine, and norepinephrine.
Increased plasma concentrations of branched-chain keto acids are transported through the blood–brain barrier via the monocarboxylate transporter. Elevated levels of alpha-ketoisocaproate result in a reduction in glutamate, glutamine, and GABA. Additionally, an influx of alpha-ketoisocaproic acid transported by a monocarboxylate transporter across the blood–brain barrier, may deplete glutamate and glutamine in astrocytes, an important type of glial cell, through transamination. Glutamate levels are maintained in the brain by BCAA metabolism functions and if not properly maintained can lead to neurological problems that are seen in MSUD individuals.
Another aspect of MSUD pathology involves the impact of elevated BCAA and BCKA on sodium-potassium ATPase activity, leading to electrolyte imbalances that contribute to cerebral edema and seizures. High leucine levels can disrupt water homeostasis in the brain's subcortical gray matter, potentially causing cerebral edema due to hyponatremia linked to increased levels of atrial natriuretic peptide and vasopressin.