Acta Paediatrica Japonica (1 996) 38, 520-523

Patient Report

Trial of docosahexaenoic acid supplementation on a Japanese patient with a peroxisome biogenesis defect

YASUYUKI SUZUKI,' NOBUYUKI SHIMOZAWA,' ATSUSHI IMAMURA,' YUKO FUKUDA,*

'Department of Pediatrics, Gifu University School of Medicine, =Department of Neonatology, Gifu Prefectural Hospital and 'Chubu Women's College, Gifu, Japan

HIROSHI ICHIHASHI,~ TADAO 0~113 AND NAOMI KONDOI

Abstract A female Japanese patient diagnosed with peroxisome biogenesis defect (PBD), who had hypotonia and craniofacial dysmorphism, was given supplementation of docosahexaenoic acid (DHA). Accumulation of very long chain fatty acids was revealed, and a diagnosis of PBD was made at 2 months of age because of the absence of peroxisomes, a defect in peroxisomal P-oxidation enzymes and a decreased level of DHA in the erythrocytes. Supplementation of DHA was introduced at 3 months of age. For the first several months, psychomotor development was fairly good. The patient could laugh, brush off a blanket and play with toys at 6 months of age. However, neurological regression and convulsions occurred after 7 months of age. After recurrent respiratory infections and disturbance of the circadian rhythm, the patient died of liver failure and disseminated intravascular coagulopathy at 20 months of age. DHA may have a favorable effect on the early development of patients with PBD, but neurological deterioration cannot be prevented. Patients with a milder phenotype would be better candidates for DHA supplementation.

Key words docosahexaenoic acid, peroxisome biogenesis defect, supplementation.

Peroxisome biogenesis disorders (PBD) are fatal auto- soma1 recessive diseases, first reported in 1964.' Zellweger syndrome (ZS) is the most severe phenotype and patients with ZS usually do not acquire any developmental milestones and seldom survive the infantile period. Manifestations of neonatal adrenoleukodystrophy (NALD) including psychomotor delay, liver dysfunction and cran- iofacial dysmorphism are milder than those of ZS. However, the prognosis for NALD patients is also poor, their mean survival age being 15 months.' Biochemical abnormalities in NALD, such as an accumulation of very long chain fatty acids (VLCFA),3 deficiency of plasmalo- gen' and absence of peroxisomes,' are indistinguishable from those of ZS. Complementation studies revealed nine groups among PBD patients: indicating the presence of at least nine pathogenic genes for PBD.'v8

Several trials for the treatment of patients with PBD have been carried out. Administration of clofibrate, a hypo-

Correspondence: Yasuyuki Suzuki, MD, Department of Pediatrics, Gifu University School of Medicine, Tsukasa-machi 40, Gifu 500, Japan.

Received 20 December 1995; revision 13 February 1996; accepted 22 March 1996.

lipidemic drug that proliferates peroxisomes in rodents, and supplementation of plasmalogen were not effective?. 10 Recently, Martinez reported that docosahexaenoic acid (DHA; C22:6), a polyunsaturated fatty acid (PUFA), was deficient in patients with PBD," and that Supplementation of DHA improved the neUrOIOgiCa1 Symptoms of mildly affected PBD patients." Here we report the clinical course of a Japanese patient with PBD receiving DHA Supple- mentation.

Patient report

A female infant was delivered at 41 weeks and 6 days from unrelated healthy Japanese parents in July 1992. Her body- weight was 2775 g and the Apgar score was 9 at 1 min and 10 at 5min. From the neonatal period, hypotonia and feeding difficulty were present. She was transferred to the neonatal intensive care unit on the third postnatal day.

On admission, mild hypotonia and head lag on the traction response were observed. Mild craniofacial dy smorphism including large anterior fontanel, frontal bossing, hyperterolism, low nasal bridge, epicanthus, low-

DHA therapy for peroxisomal disorder 521

set ears and high arched palate were observed, Calcific stippling of the patella, simian crease of the left palm, pes equinovarus and peripheral pulmonary artery stenosis were also noticed. Retinitis pigmentosa was not observed.

The results of routine laboratory examination were as follows: venous blood pH 7.399, Pco, 32.8 mmHg, PO, 52.5 mmHg, glucose 75 mg/dL, Na 144 mEq/L, K 4.0mEq/L, Ca4.6 mEq/L, white blood cell count 12 2W/mm3, red blood cell count 7 X 106/mm3, Hb 20.9 g/dL, platelets 2.3 X l@/mm3, SGOT 159 IUL, SGPT 40 IUL, LDH 2755 IUL, CPK 548 IUL, BUN 4 mg/dL, creatinine 0.1 mg/dL, total bilirubin 8.4 mg/dL, total protein 6.2 g/dL, CRP 1.3 mg/dL. IgA < 7.6 mg/dL, IgM 21.4 mg/dL, IgG 1199 mg/dL. She had a normal female karyotype.

VLCFA analysis in serum ~phingomyelin'~ revealed a marked elevation of tetracosanoic acid (C24:0), penta- cosanoic acid (C25:O) and hexacosanoic acid (C26:O). Increased excretion of 2-hydroxysebacate and p-hydroxy- phenyllactate in the urine was also detected. DHA level, as shown by the ratio of DHNpalmitic acid (C16:O) in the red blood cells, was severely decreased. The C24:O oxidation rate and the activity of dihydroxyacetone phosphate acyltransferase in cultured skin fibroblasts were also severely decreased (Table 1). Immunoblot analyses of the P-oxidation enzymes in fibroblasts revealed an absence of enzyme proteins. Peroxisomes were severely decreased in the fibroblasts. A complementation demonstrated that the patient belonged to group El3 (data not shown).

Supplementation of DHA and clinical course

During the first 2 months, the patient could gradually suck breast milk and her bodyweight increased. At 3 months of age, she could respond to her mother's voice and move her

Table 1 Biochemical data

Patient

Serum sphingomyelin C24:O/C22:0 C25:O/C22:0 C26:0/C22:0

Erythrocyte DHNC 16:O C24:O oxidation'

p-oxidation enzyme Peroxisomes Complementation

DHAP-AT**

1.53 0.15 0.06 0.02

0.05 Deficient Reduced Group E

30

Control

0.62 i 0.1 1 0.02 f 0.006

0.006 i 0.003 0.22 f 0.13 432f 112 1.64 f 0.56

Present Present

-

*Tetracosanoic acid oxidation (pmolh mg protein). **Dihydroxyacetone phosphate acyltransferase (nmolh mg

protein).

neck and limbs. The liver was soft and palpable 3 cm below the ribs and the anterior fontanel was 6 x 7 cm.

For the first months, breast milk and a formula supple- mented with DHA (9 mg/dL; Meiji Milk Co., Tokyo, Japan) were given. At 4 months of age, supplementation of partially purified fish oil (1 &day) that contained 35% of DHA and 10% of eicosapentaenoic acid was introduced (Harima Chemical Co., Osaka, Japan).'* At that time, the patient played with her hands in a supine position. Supplementation of vitamin K (1 mgkg per week) was started because of the decreased blood coagulation value. The liver was palpable 3 cm below the ribs and serum transaminases began to decrease. Magnetic resonance imaging showed poor myelinogenesis, but no other abnormal findings were observed. Nystagmus was first observed at 5 months of age. At 6 months she could laugh, bwsh off her blanket with her legs and play with toys in her hands. The level of the erythrocyte DHA/C16:0 ratio increased to within the normal range (Fig. 1).

The first episode of clonic convulsion was noticed at 7 months of age. At 9 months, supplementation of DHA was stopped for 1 month because of intestinal bleeding of unknown origin. An electro-encephalogram revealed multi- focal spikes in the bilateral hemisphere. Administration of valploic acid (20mg/kg per day) was commenced at 11 months of age. Around that time, the patient suffered from recurrent atelectasis and bronchitis, disturbed circadian rhythm, ill temper and sporadic fever up to 38°C. Her bodyweight began to decrease. Hard liver was palpable 4cm below the ribs. The auditory brainstem response showed only the I wave on the right side and the I and V wave on the left side.

At 15 months of age convulsions increased, and clubbed fingers and palmar erythema appeared. Gavage feeding was introduced at 18 months of age. The size of the liver, serum transaminases and cholinesterase gradually decreased. The patient was hospitalized at 19 months of age because of infantile diarrhea and hypertonic dehydration. Prolonged prothrombin time, hyperammonemia. increased total biliru- bin (6.2 mg/dL) and hypoglycemia (30 mg/dL) were also observed. At 20 months of age, she died of pneumonia, disseminated intravascular coagulopathy and multiple organ failure (Fig. 1). Permission for an autopsy was not obtained.

Discussion

DHA is a type of n-3 PUFA and is abundant in marine fish oil. It is also synthesized from a-linolenic acid (C18:3), an essential n-3 PUFA. Hence, DHA is considered to be a

522 Y Suzuki et al.

Age 0 3 6 9 12 15 18 20 (months)

~~~ ~~

B W 2.8 4.4 5.8 6.4 6.1 5.6 5.0 6.3 kg

DHA - DHA/Cl6 0.03 0.22 0.1 5 0.08 (0.22f0.13)

Liver 0 3 3 4 4 3 1 1 cm

50 @day 350 mg/day 350 mg/day

Development smile - - hand regard Neurological regression

nystagmus

Complication intestinal a telec tasis Liver failurelDIC bleeding pneumonia MOF

Therapy V.K2 (I/w) anticonvulsant (VPA)

H2 antagonist antibiotics- - - -

ventilation - glucocorticoid -

anti-DIC -

GOT 159 527 331 319 184 211 97 119 IU/L GPT 40 310 261 103 50 46 18 2 9 IU/L LDH 2755 913 710 667 698 913 766 IU/L

chE 0.6 0.1 ApH NH3 84 215 ccg/dL CK 5 4 8 120 66 18 IU/L PT 69 <10 55 53 68 46 40 17 Yo

type of essential fatty acid. In humans, DHA is rich in the central nervous system, retina, heart, sperm and breast milk. DHA is considered to be important for the development of the brain and higher brain functions such as learning, memory and emotion.15J6

Martinez first reported the deficiency of DHA in tissues and erythrocytes from patients with PBD," and speculated that the final step for desaturation of n-3 PUFA is localized in peroxisomes and therefore DHA cannot be synthesized in patients with PBD. Martinez et al. administered fish oil (5 &day) then highly purified DHA ethyl ester (250 mg/day) to two patients with PBD, one with a milder variant of NALD (6 years old) and one with severe NALD (3 years old).I2 The milder case was noticed because of elevated transaminases at 6 months of age. He could walk alone at 2 years of age, then regression occurred after 3 years of age. After treatment, he showed significant improvement in neurological findings: decreased spasticity, improved visual evoked potentials and fine motor skills. However, in the patient with severe NALD, who could not achieve head control or sit alone, DHA supplementation was not effective and he died within a few months.

The clinical manifestations of our patient in the early

Fig. 1 Clinical course of the patient. BW, bodyweight; DHA, docosahexaenoic acid; GOT, aspartate minotransferase; Gm, alanine minotransferase; LDH lactate dehydrogenase; chE, cho& esterase; CK, creatine kinase; PT, prothrombin time; DIC, dis- seminated intravascular coag- ulopathy; MOF, multiple organ failure.

infantile period were more severe than those of the former case and similar to those of the latter case; the efficacy of DHA being questionable. We tried DHA supplementation from the early infantile period, expecting an enhancement of psychomotor development. The patient developed fairly well up to 6 months of age, which correlated with tl-,e increase in erythrocyte DHA (Fig. 1). Although it is difficult to evaluate whether the clinical course of the present case was a natural one or was altered by the admin- istration of DHA, our experience suggests that DHA may have a favorable effect on early neurological development. Further investigations are required on the effects of DHA on the clinical course of PBD. Patients with milder PBD would be better candidates for DHA supplementation.

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