Medscape is available in 5 Language Editions – Choose your Edition here.


Holocarboxylase Synthetase Deficiency Follow-up

  • Author: Karl S Roth, MD; Chief Editor: Luis O Rohena, MD  more...
Updated: Nov 03, 2015

Further Outpatient Care

With regular biotin administration, frequent follow-up visits to a specialist should not be required for patients with holocarboxylase synthetase (HCS) deficiency.

Growth and development should be closely observed to address residual morbidity from the initial insult.


Inpatient & Outpatient Medications

Biotin is the only medication necessary for treatment.



Prolonged failure to adhere to the daily biotin requirement results in an insidious onset of the underlying disease, with potentially life-threatening consequences.



Early and consistent treatment allows for an excellent prognosis.


Patient Education

Families must not become sanguine during biotin administration because affected infants appear so healthy.

Teenaged patients often rebel against taking daily medication, despite the fact that biotin is an odorless, tasteless capsule.

Contributor Information and Disclosures

Karl S Roth, MD Retired Professor and Chair, Department of Pediatrics, Creighton University School of Medicine

Karl S Roth, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Nutrition, American Pediatric Society, American Society for Nutrition, American Society of Nephrology, Association of American Medical Colleges, Medical Society of Virginia, New York Academy of Sciences, Sigma Xi, Society for Pediatric Research, Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Margaret M McGovern, MD, PhD Professor and Chair of Pediatrics, Stony Brook University School of Medicine

Margaret M McGovern, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Society of Human Genetics

Disclosure: Nothing to disclose.

Chief Editor

Luis O Rohena, MD Chief, Medical Genetics, San Antonio Military Medical Center; Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Assistant Professor of Pediatrics, University of Texas Health Science Center at San Antonio

Luis O Rohena, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American College of Medical Genetics and Genomics, American Society of Human Genetics

Disclosure: Nothing to disclose.

Additional Contributors

Christian J Renner, MD Consulting Staff, Department of Pediatrics, University Hospital for Children and Adolescents, Erlangen, Germany

Disclosure: Nothing to disclose.

  1. Roth K, Cohn R, Yandrasitz J, Preti G, Dodd P, Segal S. Beta-methylcrotonic aciduria associated with lactic acidosis. J Pediatr. 1976 Feb. 88(2):229-35. [Medline].

  2. Saunders M, Sweetman L, Robinson B, Roth K, Cohn R, Gravel RA. Biotin-response organicaciduria. Multiple carboxylase defects and complementation studies with propionicacidemia in cultured fibroblasts. J Clin Invest. 1979 Dec. 64(6):1695-702. [Medline].

  3. Roth KS, Yang W, Foremann JW, Rothman R, Segal S. Holocarboxylase synthetase deficiency: a biotin-responsive organic acidemia. J Pediatr. 1980 May. 96(5):845-9. [Medline].

  4. Burri BJ, Sweetman L, Nyhan WL. Mutant holocarboxylase synthetase: evidence for the enzyme defect in early infantile biotin-responsive multiple carboxylase deficiency. J Clin Invest. 1981 Dec. 68(6):1491-5. [Medline].

  5. Wolf B, Grier RE, Parker WD Jr, Goodman SI, Allen RJ. Deficient biotinidase activity in late-onset multiple carboxylase deficiency. N Engl J Med. 1983 Jan 20. 308(3):161. [Medline].

  6. Tammachote R, Janklat S, Tongkobpetch S, Suphapeetiporn K, Shotelersuk V. Holocarboxylase synthetase deficiency: novel clinical and molecular findings. Clin Genet. 2010 Jul. 78(1):88-93. [Medline].

  7. Zempleni J, Li Y, Xue J, Cordonier EL. The role of holocarboxylase synthetase in genome stability is mediated partly by epigenomic synergies between methylation and biotinylation events. Epigenetics. 2011 Jul. 6(7):892-4. [Medline]. [Full Text].

  8. Bailey LM, Ivanov RA, Jitrapakdee S, Wilson CJ, Wallace JC, Polyak SW. Reduced half-life of holocarboxylase synthetase from patients with severe multiple carboxylase deficiency. Hum Mutat. 2008 Jun. 29(6):E47-57. [Medline].

  9. Mayende L, Swift RD, Bailey LM, et al. A novel molecular mechanism to explain biotin-unresponsive holocarboxylase synthetase deficiency. J Mol Med (Berl). 2012 Jan. 90(1):81-8. [Medline].

  10. Slavin TP, Zaidi SJ, Neal C, Nishikawa B, Seaver LH. Clinical Presentation and Positive Outcome of Two Siblings with Holocarboxylase Synthetase Deficiency Caused by a Homozygous L216R Mutation. JIMD Rep. 2013 Sep 13. [Medline].

  11. [Guideline] Cunniff C. Prenatal screening and diagnosis for pediatricians. Pediatrics. 2004 Sep. 114(3):889-94. [Medline]. [Full Text].

  12. De Castro M, Zand DJ, Lichter-Konecki U, Kirmse B. Severe neonatal holocarboxylase synthetase deficiency in west african siblings. JIMD Rep. 2015. 20:1-4. [Medline].

  13. Wilson CJ, Myer M, Darlow BA, Stanley T, Thomson G, Baumgartner ER, et al. Severe holocarboxylase synthetase deficiency with incomplete biotin responsiveness resulting in antenatal insult in samoan neonates. J Pediatr. 2005 Jul. 147(1):115-8. [Medline].

  14. Eldjarn L, Jellum E, Stokke O, Pande H, Waaler PE. Beta-hydroxyisovaleric aciduria and beta-methylcrotonylglycinuria: a new inborn error of metabolism. Lancet. 1970 Sep 5. 2(7671):521-2. [Medline].

  15. Gompertz D, Draffan GH, Watts JL, Hull D. Biotin-responsive beta-methylcrotonylglycinuria. Lancet. 1971 Jul 3. 2(7714):22-4. [Medline].

  16. Gompertz D, Goodey PA, Bartlett K. Evidence for the enzymic defect in beta-methylcrotonylglycinuria. FEBS Lett. 1973 May 15. 32(1):13-4. [Medline].

  17. Malvagia S, Morrone A, Pasquini E, Funghini S, la Marca G, Zammarchi E, et al. First prenatal molecular diagnosis in a family with holocarboxylase synthetase deficiency. Prenat Diagn. 2005 Dec. 25(12):1117-9. [Medline].

  18. Nyhan WL, Willis M, Barshop BA, Gangoiti J. Positive newborn screen in the biochemically normal infant of a mother with treated holocarboxylase synthetase deficiency. J Inherit Metab Dis. 2009 Apr 11. [Medline].

  19. Pacheco-Alvarez D, Solorzano-Vargas RS, Gravel RA, Cervantes-Roldan R, Velazquez A, Leon-Del-Río A. Paradoxical regulation of biotin utilization in brain and liver and implications for inherited multiple carboxylase deficiency. J Biol Chem. 2004 Dec 10. 279(50):52312-8. [Medline].

  20. Santer R, Muhle H, Suormala T, Baumgartner ER, Duran M, Yang X, et al. Partial response to biotin therapy in a patient with holocarboxylase synthetase deficiency: clinical, biochemical, and molecular genetic aspects. Mol Genet Metab. 2003 Jul. 79(3):160-6. [Medline].

  21. Suormala T, Fowler B, Duran M, Burtscher A, Fuchshuber A, Tratzmüller R, et al. Five patients with a biotin-responsive defect in holocarboxylase formation: evaluation of responsiveness to biotin therapy in vivo and comparative biochemical studies in vitro. Pediatr Res. 1997 May. 41(5):666-73. [Medline].

  22. Yang X, Aoki Y, Li X, Sakamoto O, Hiratsuka M, Kure S, et al. Structure of human holocarboxylase synthetase gene and mutation spectrum of holocarboxylase synthetase deficiency. Hum Genet. 2001 Nov. 109(5):526-34. [Medline].

Urea cycle. Compounds that comprise the urea cycle are numbered sequentially, beginning with carbamyl phosphate. At the first step (1), the first waste nitrogen is incorporated into the cycle; also at this step, N-acetylglutamate exerts its regulatory control on the mediating enzyme, carbamyl phosphate synthetase (CPS). Compound 2 is citrulline, the product of condensation between carbamyl phosphate (1) and ornithine (8); the mediating enzyme is ornithine transcarbamylase. Compound 3 is aspartic acid, which is combined with citrulline to form argininosuccinic acid (4); the reaction is mediated by argininosuccinate (ASA) synthetase. Compound 5 is fumaric acid generated in the reaction that converts ASA to arginine (6), which is mediated by ASA lyase.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.