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LETTER TO EDITOR
Year : 2014  |  Volume : 3  |  Issue : 1  |  Page : 55-56

Maple syrup urine disease and oculocutaneous albinism in twins


Department of Pediatrics, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Web Publication14-Mar-2014

Correspondence Address:
Divya Nagabushana
Department of Pediatrics, M S Ramaiah Medical College, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4847.128744

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How to cite this article:
Nagabushana D, Benakappa A. Maple syrup urine disease and oculocutaneous albinism in twins. J Clin Neonatol 2014;3:55-6

How to cite this URL:
Nagabushana D, Benakappa A. Maple syrup urine disease and oculocutaneous albinism in twins. J Clin Neonatol [serial online] 2014 [cited 2019 Dec 5];3:55-6. Available from: http://www.jcnonweb.com/text.asp?2014/3/1/55/128744

Sir,

Maple syrup urine disease (MSUD) is an inborn error of metabolism (IEM) characterized by a defect in the catabolic pathway of branched-chain amino acids resulting from a deficiency of branched-chain α-ketoacid dehydrogenase. Classic MSUD presents with life-threatening clinical manifestations in the neonatal period. [1] Twins, in the newborn period, presented to the neonatal intensive care unit (ICU) with unexplained encephalopathy and abnormal urine odor with one twin manifesting oculocutaneous albinism. They were both diagnosed as having MSUD. MSUD is inherited in an autosomal recessive fashion and occurs in 1 in 200,000 individuals. [2] Oculocutaneous albinism has a prevalence of 1/40,000. [3] It has an autosomal recessive inheritance pattern and is a disorder of melanin biosynthesis. MSUD in monozygotic twins has been reported in the literature. [4] However, there has been no report on the occurrence of MSUD and oculocutaneous albinism in a single individual so far.

Twins, males, born to a healthy mother were extracted by elective cesarean section with birth weights of 2.3 kg and 2 kg [Figure 1]. Both cried immediately after birth and were started on direct breastfeeds soon after birth. The first twin presented to the neonatal ICU on the 6 th day of life with lethargy, refusal of feeds and hurried breathing. Hypopigmented skin, hair and iris were also noted, which is diagnostic of oculocutaneous albinism. The second twin was admitted a day later with similar complaints, but did not have any hypopigmentation. The parents had a second degree consanguineous marriage with history of albinism in the maternal grand-mother, and neonatal deaths and miscarriages in the extended family. On examination, abnormal urine odor, similar to that of burnt sugar, was noted in both the babies. Both had a weight loss exceeding 500 g in the 1 st week of life. Tachypnea, gross hypotonia and poor reflexes were observed in both siblings.
Figure 1: Picture of twins with the one on the left having oculocutaneous albinism

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Severe hypoglycemia was present in both neonates at admission. Despite dextrose infusion and other supportive management, the condition of both neonates deteriorated further, with refractory hypoglycemia. Lab results revealed metabolic acidosis with increased anion gap. Sepsis screen in both were negative. Urine analysis revealed presence of ketone bodies and did not have any reducing substances. Elevated ammonia levels and lactic acidosis observed helped to narrow down the differential diagnosis to organic acidemia. Tandem mass spectrometry revealed elevated leucine, isoleucine and valine in the twins, confirming the diagnosis of MSUD. The neonates were treated with thiamine, carnitine, vitamin cocktail, dextrose infusion and supportive management.

Unexplained encephalopathy, high anion gap metabolic acidosis, severe hypoglycemia, abnormal urine odor and a negative sepsis screen are pointers for IEM in neonatal period. The presence of hyperammonemia, lactic acidosis, ketonuria with hypoglycemia is unique to organic acidemias. Though rare, IEM is a condition seen periodically in clinical practice. Timely diagnosis and appropriate management can lead to better quality of life with decreased morbidities in affected children.


  Acknowledgment Top


We thank the Department of Neurobiochemistry, National Institute of Mental Health and Neurosciences, Bangalore, for the evaluation of the clinical samples.

 
  References Top

1.Christopher R, Babu SV, Nirmala L, Rangaswamy GR, Narayan CP, Shetty KT. Maple syrup urine disease: An uncommon cause for neonatal metabolic distress. Indian J Clin Biochem 1999;14:198-206.  Back to cited text no. 1
    
2.Campistol J. Inborn errors of metabolism with neurological manifestations in the neonatal period. Medicina (B Aires) 2007;67:561-8.  Back to cited text no. 2
    
3.King RA, Hearing VJ, Creel DJ, Oetting WS. Albinism. In: Scriver CR, Beaudet AL, Sly WS, Valle D, editors. The Metabolic and Molecular Bases of Inherited Disease. New York: McGraw-Hill, Inc.; 1995. p. 4353-92.  Back to cited text no. 3
    
4.Joy R, Kumar P, Femitha P, Gane BD, Adhisivam B, Bhat VB. Double trouble with maple. Curr Pediatr Res 2013;17:67-9.  Back to cited text no. 4
    


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