eMedicine Specialties > Pediatrics: Genetics and Metabolic Disease > Metabolic Diseases

Propionic Acidemia (Propionyl CoA Carboxylase Deficiency): Differential Diagnoses & Workup

Author: Karl S Roth, MD, Professor and Chair, Department of Pediatrics, Creighton University School of Medicine
Contributor Information and Disclosures

Updated: Sep 10, 2009

Differential Diagnoses

Hyperammonemia
Methylmalonic Acidemia

Other Problems to Be Considered

Multiple carboxylase (holocarboxylase) deficiency

Workup

Laboratory Studies

  • A basic metabolic panel is indicated in propionyl coenzyme A (CoA) carboxylase deficiency (ie, propionic acidemia). Serum electrolyte measurement is important. A child who is feeding poorly and vomits may have significant electrolyte abnormalities. Accumulation of free organic acids (anions) significantly increases the anion gap. Therefore, an anion gap larger than 16 mEq/L may indicate propionic acidemia. On rare occasions, affected babies do not present with an increased anion gap.
  • Because free propionic acid is known to suppress bone marrow, assessing the status of circulating elements, including platelets, is important.
  • Specific gravity, obtained through a routine urinalysis, is important in assessing the degree of dehydration. The presence of ketones in association with an anion gap (as mentioned above) is strongly suggestive of ketoacidosis. A low urine pH lends additional weight to this suspicion.
  • Obtaining blood ammonia levels is important in the assessment of the overall metabolic status of the patient, as well as to help in determination of causes for mental status changes. Blood ammonia levels are often secondarily elevated.
  • Obtaining plasma lactate levels is helpful in the determination of the causes for an observed anion gap. Lactate levels are often elevated but are not sufficiently high enough to account for the increase in anion gap, which should then prompt further investigation.
  • Assessing the urinary organic acid levels is the definitive clinical diagnostic study. Most frequently, it demonstrates large increases in beta-hydroxy propionic acid, lactic acid, and methylcitrate excretion levels.
  • Leukocyte propionyl CoA carboxylase activity is the study required for definitive biochemical diagnosis and appropriate genetic counseling.

Other Tests

  • ECG is recommended in all patients because of the frequency of prolonged QTc intervals and decreased left ventricular contractility reported in patients with propionic acidemia.
  • Further evaluation with continuous ECG monitoring and echocardiography should be considered.

Histologic Findings

  • A diagnosis of propionic acidemia that is missed in life is extremely difficult to make postmortem.

More on Propionic Acidemia (Propionyl CoA Carboxylase Deficiency)

Overview: Propionic Acidemia (Propionyl CoA Carboxylase Deficiency)
Differential Diagnoses & Workup: Propionic Acidemia (Propionyl CoA Carboxylase Deficiency)
Treatment & Medication: Propionic Acidemia (Propionyl CoA Carboxylase Deficiency)
Follow-up: Propionic Acidemia (Propionyl CoA Carboxylase Deficiency)
Multimedia: Propionic Acidemia (Propionyl CoA Carboxylase Deficiency)
References
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References

  1. Hsia YE, Scully KJ, Rosenberg LE. Defective propionate carboxylation in ketotic hyperglycinaemia. Lancet. Apr 12 1969;1(7598):757-8. [Medline].

  2. Morrow G 3rd, Barness LA, Auerbach VH, et al. Observations on the coexistence of methylmalonic acidemia and glycinemia. J Pediatr. May 1969;74(5):680-90. [Medline].

  3. Hsia YE, Scully KJ, Rosenberg LE. Inherited propionyl-Coa carboxylase deficiency in "ketotic hyperglycinemia.". J Clin Invest. Jan 1971;50(1):127-30. [Medline]. [Full Text].

  4. Bruggink JL, van Spronsen FJ, Wijnberg-Williams BJ, Bos AF. Pilot use of the early motor repertoire in infants with inborn errors of metabolism: outcomes in early and middle childhood. Early Hum Dev. Jul 2009;85(7):461-5. [Medline].

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

  6. Baumgartner D, Scholl-Burgi S, Sass JO, et al. Prolonged QTc intervals and decreased left ventricular contractility in patients with propionic acidemia. J Pediatr. Feb 2007;150(2):192-7. [Medline].

  7. Feliz B, Witt DR, Harris BT. Propionic acidemia: a neuropathology case report and review of prior cases. Arch Pathol Lab Med. Aug 2003;127(8):e325-8. [Medline].

  8. Filipowicz HR, Ernst SL, Ashurst CL, Pasquali M, Longo N. Metabolic changes associated with hyperammonemia in patients with propionic acidemia. Mol Genet Metab. Jun 2006;88(2):123-30. [Medline].

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  13. Nyhan WL, Bordern M, Childs B. Idiopathic hyperglycinemia: a new disorder of amino acid metabolism. II. The concentrations of other amino acids in the plasma and their modification by the administration of leucine. Pediatrics. Apr 1961;27:539-50. [Medline].

  14. Perez-Cerda C, Perez B, Merinero B, et al. Prenatal diagnosis of propionic acidemia. Prenat Diagn. Dec 15 2004;24(12):962-4. [Medline].

  15. Saunders M, Sweetman L, Robinson B, et al. Biotin-response organic aciduria. Multiple carboxylase defects and complementation studies with propionic acidemia in cultured fibroblasts. J Clin Invest. Dec 1979;64(6):1695-702. [Medline]. [Full Text].

  16. Wolf B, Willard HF, Rosenberg LE. Kinetic analysis genetic complementation in heterokaryons of propionyl CoA carboxylase-deficient human fibroblasts. Am J Hum Genet. 1980;32(1):16-25. [Medline].

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Further Reading

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Keywords

propionic acidemia, ketotic hyperglycinemia, propionyl coenzyme A carboxylase deficiency, propionate carboxylation defect, multiple carboxylase deficiency, propionyl-CoA carboxylase deficiency, severe ketoacidosis, protein ingestion, hyperammonemia, pancytopenia, acidosis, mental retardation, pancytopenia, failure to thrive, feeding intolerance, anorexia

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Contributor Information and Disclosures

Author

Karl S Roth, MD, 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 Clinical 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, and Southern Society for Pediatric Research
Disclosure: MDS Pharma Salary Employment

Medical Editor

Erawati V Bawle, MD, FAAP, FACMG, Division of Genetic and Metabolic Disorders, Children's Hospital of Michigan; Professor (Clinician-Educator), Department of Pediatrics, Wayne State University School of Medicine
Erawati V Bawle, MD, FAAP, FACMG is a member of the following medical societies: American Academy of Pediatrics, American College of Medical Genetics, American Medical Association, and American Society of Human Genetics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert Anthony Saul, MD, Clinical Professor, Department of Pediatrics, University of South Carolina; Senior Clinical Geneticist, Greenwood Genetic Center
Robert Anthony Saul, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Medical Genetics, and American College of Physician Executives
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Bruce Buehler, MD, Professor of Genetics, Munroe Meyer Institute, Professor, Department of Pediatrics, Pathology and Microbiology, University of Nebraska Medical Center
Bruce Buehler, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Pediatrics, American Association on Mental Retardation, American College of Medical Genetics, American College of Physician Executives, American Medical Association, and Nebraska Medical Association
Disclosure: Nothing to disclose.

 
 
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