Phenylketonuria
Phenylketonuria is an inborn error of metabolism that results in decreased metabolism of the amino acid phenylalanine. Untreated PKU can lead to intellectual disability, seizures, behavioral problems, and mental disorders. It may also result in a musty smell and lighter skin. A baby born to a mother who has poorly treated PKU may have heart problems, a small head, and low birth weight.
Phenylketonuria is an inherited genetic disorder. It is caused by mutations in the PAH gene, which can result in inefficient or nonfunctional phenylalanine hydroxylase, an enzyme responsible for the metabolism of excess phenylalanine. This results in the buildup of dietary phenylalanine to potentially toxic levels. It is autosomal recessive, meaning that both copies of the gene must be mutated for the condition to develop. The two main types are classic PKU and variant PKU, depending on whether any enzyme function remains. Those with one copy of a mutated gene typically do not have symptoms. Many countries have newborn screening programs for the disease.
Treatment is with a diet low in foods that contain phenylalanine and includes special supplements. Babies should use a special formula with a small amount of breast milk. The diet should begin as soon as possible after birth and continue for life. People who are diagnosed early and maintain a strict diet can have normal health and a normal lifespan. Effectiveness is monitored through periodic blood tests. The medication sapropterin dihydrochloride may be useful in some.
Phenylketonuria affects about one in 12,000 babies. Males and females are affected equally. The disease was discovered in 1934 by Ivar Asbjørn Følling, with the importance of diet determined in 1935. As of 2023, genetic therapies that aim to directly restore liver PAH activity are a promising and active research field.
Signs and symptoms
Untreated PKU can lead to intellectual disability, seizures, behavioral problems, and mental disorders. It may also result in a musty smell and lighter skin. A baby born to a mother who has poorly treated PKU may have heart problems, a small head, and low birth weight.Because the mother's body is able to break down phenylalanine during pregnancy, infants with PKU are normal at birth. The disease is not detectable by physical examination at that time, because no damage has yet been done. Newborn screening is performed to detect the disease and initiate treatment before any damage is done. The blood sample is usually taken by a heel prick, typically performed 2–7 days after birth. This test can reveal elevated phenylalanine levels after one or two days of normal infant feeding.
If a child is not diagnosed during the routine newborn screening test and a phenylalanine-restricted diet is not introduced, then phenylalanine levels in the blood will increase over time. Toxic levels of phenylalanine, along with insufficient levels of tyrosine, can interfere with infant development in ways that have permanent effects. The disease may present clinically with seizures, hypopigmentation, and a "musty odor" to the baby's sweat and urine. In most cases, a repeat test should be done around two weeks of age to verify the initial test and uncover any phenylketonuria that was initially missed.
Untreated children often fail to attain early developmental milestones, develop microcephaly, and demonstrate progressive impairment of cerebral function. Hyperactivity, EEG abnormalities, seizures, and severe learning disabilities are major clinical problems later in life. A characteristic "musty or mousy" odor on the skin, as well as a predisposition for eczema, persists throughout life in the absence of treatment.
The damage done to the brain if PKU is untreated during the first months of life is not reversible. Affected children who are detected at birth and treated are much less likely to develop neurological problems or have seizures and intellectual disability, though such clinical disorders are still possible including asthma, eczema, anemia, weight gain, renal insufficiency, osteoporosis, gastritis, esophagus, and kidney deficiencies, kidney stones, and hypertension. Additionally, mood disorders occur 230% higher than controls; dizziness and giddiness occur 180% higher; chronic ischemic heart disease, asthma, diabetes, and gastroenteritis occur 170% higher; and stress and adjustment disorder occur 160% higher. In general, however, outcomes for people treated for PKU are good. Treated people may have no detectable physical, neurological, or developmental problems at all.
Genetics
PKU is an autosomal recessive metabolic genetic disorder. As such, two PKU alleles are required for an individual to experience symptoms of the disease. For a child to inherit PKU, both parents must have and pass on the defective gene. If both parents are carriers for PKU, any child they have will have a 25% chance to be born with the disorder, a 50% chance the child will be a carrier, and a 25% chance the child will neither develop nor be a carrier for the disease.PKU is characterized by homozygous or compound heterozygous mutations in the gene for the hepatic enzyme phenylalanine hydroxylase, rendering it nonfunctional. This enzyme is necessary to metabolize the amino acid phenylalanine to the amino acid tyrosine. When PAH activity is reduced, Phe accumulates and is converted into phenylpyruvate, which can be detected in the urine.
Carriers of a single PKU allele do not exhibit symptoms of the disease, but appear to be protected to some extent against the fungal toxin ochratoxin A. Louis Woolf suggested that this accounted for the persistence of the allele in certain populations, in that it confers a selective advantage—in other words, being a heterozygote is advantageous.
The gene for PAH is located on chromosome 12 in the bands 12q22-q24.2. As of 2000, around 400 disease-causing mutations had been found in the PAH gene. This is an example of allelic genetic heterogeneity.
Pathophysiology
When phenylalanine cannot be metabolized by the body, a typical diet that would be healthy for people without PKU causes abnormally high levels of phenylalanine to accumulate in the blood, which is toxic to the brain. If left untreated, complications of PKU include severe intellectual disability, brain function abnormalities, microcephaly, mood disorders, irregular motor functioning, and behavioral problems such as attention deficit hyperactivity disorder, as well as physical symptoms such as a "musty" odor, eczema, and unusually light skin and hair coloration.Classical PKU
Classical PKU, and its less severe forms "mild PKU" and "mild hyperphenylalaninemia" are caused by a mutated gene for the enzyme phenylalanine hydroxylase, which converts phenylalanine to tyrosine, which is a conditionally essential amino acid for PKU patients, because without the enzyme PAH, tyrosine cannot be produced in the body through oxidation of Phe.PAH deficiency causes a spectrum of disorders, including classic phenylketonuria and mild hyperphenylalaninemia, a less severe accumulation of phenylalanine. Compared to classic PKU patients, patients with "hyperPhe" have greater PAH enzyme activity and are able to tolerate larger amounts of phenylalanine in their diets. Without dietary intervention, mild HPA patients have blood Phe levels higher than those people with normal PAH activity. Currently, no international consensus exists on the definition of mild HPA, but it is most frequently diagnosed at blood Phe levels between 2 and 6 mg/dL.
Phenylalanine is a large, neutral amino acid. LNAAs compete for transport across the blood–brain barrier via the large neutral amino acid transporter. If phenylalanine is in excess in the blood, it saturates the transporter. Excessive phenylalanine levels tend to decrease the levels of other LNAAs in the brain. As these amino acids are necessary for protein and neurotransmitter synthesis, Phe buildup disrupts the development of the brain, causing intellectual disability.
Recent research suggests that neurocognitive, psychosocial, quality of life, growth, nutrition, and bone pathology are slightly suboptimal even for patients who are treated and maintain their Phe levels in the target range if their diets are not supplemented with other amino acids.
Classic PKU affects myelination and white-matter tracts in untreated infants; this may be one major cause of neurological problems associated with phenylketonuria. Differences in white-matter development are observable with magnetic resonance imaging. Abnormalities in the gray matter can also be detected, particularly in the motor and premotor cortex, thalamus, and the hippocampus.
PKU may resemble amyloid diseases, such as Alzheimer's disease and Parkinson's disease, due to the formation of toxic amyloid-like assemblies of phenylalanine.
Tetrahydrobiopterin-deficient hyperphenylalaninemia
A rarer form of hyperphenylalaninemia is tetrahydrobiopterin deficiency, which occurs when the PAH enzyme is normal, and a defect is found in the biosynthesis or recycling of the cofactor tetrahydrobiopterin. BH4 is necessary for proper activity of the enzyme PAH, and this coenzyme can be supplemented as treatment. Those with this form of hyperphenylalaninemia may have a deficiency of tyrosine, in which case treatment is supplementation of tyrosine to account for this deficiency.Levels of dopamine can be used to distinguish between these two types. Tetrahydrobiopterin is required to convert Phe to Tyr and is required to convert Tyr to L-DOPA via the enzyme tyrosine hydroxylase. L-DOPA, in turn, is converted to dopamine. Low levels of dopamine lead to high levels of prolactin. By contrast, in classical PKU, prolactin levels would be relatively normal.
As of 2020, tetrahydrobiopterin deficiency was known to result from defects in five genes.