Am J Hum Genet 32:781-792, 1980

Review Article

An Introduction to Gas Chromatography-Mass Spectrometry and

the Inherited Organic Acidemias
STEPHEN I. GOODMAN1

INTRODUCTION
The organic acidemias comprise a group of inborn errors of amino acid metabolism
characterized not by aminoacidemia or aminoaciduria but by the accumulation and
excretion of acids that do not contain an amino group and that, therefore, do not react
with ninhydrin. As such, they can be detected only by procedures specifically designed
to examine these "organic acids" in serum or urine. The organic acids in these fluids
are so numerous, however, and their concentrations so altered by the intake of drugs
and various foodstuffs or by changes in intestinal flora, that their analysis requires
extremely complex instrumentation. Gas chromatography-mass spectrometry (GC/
MS), an instrument combination that simultaneously separates and identifies the
components of a complex mixture, is particularly well suited to the analysis of organic
acids and is now widely used to screen for and to investigate these diseases. This paper
will briefly review the elements of GC/MS and provide some current information about
diagnosis, pathogenesis, and treatment of the organic acidemias.
GC/MS
Gas chromatography (GC) is a procedure in which the volatile components of a
mixture are separated by partitioning between a moving, inert gas (carrier gas) and a
nonvolatile liquid (the stationary phase) [1]. The latter is contained in a column and is
coated onto an inert, size-graded solid (the stationary support). The carrier gas is
passed through the column as column temperature is raised and, as components of the
mixture leave the stationary phase, they are carried to a detector and become recorded
as a series of peaks. Most of the organic acids in physiological fluids are not volatile
enough to be analyzed by GC, but volatile methylated or trimethylsilyl derivatives can
Received February 20, 1980; revised April 28, 1980.
This research was supported in part by Maternal and Child Health Special Project No. 252.
1 Department of Pediatrics, University of Colorado Health Sciences Center School of Medicine, 4200 East
Ninth Avenue, Denver, CO 80262.
© 1980 by the American Society of Human Genetics. 0002-9297/80/3206-0001$02.00
781
MEDICAL LIBRARY
HISTORICAL BULDING
DES MOINES, tOWA
782 GOODMAN
be made quite easily, and an "organic-acid profile," as the one shown in figure 1, can
be generated in any laboratory with a gas chromatograph. Any of the many published
specific techniques can be used providing that one becomes accustomed to the normal
patterns and to the artifacts of the system.
It is rare that an organic acidemia can be diagnosed on the basis of the profile alone,
however, because large peaks in almost any area of the chromatogram will be due
much more often to variations in the normal excretion pattern or to drugs or food
additives than to the abnormal acids characteristic of disease. Adequate interpretation
of the profile, thus, requires that peaks be identified, and, while there are many ways to
do this, most of them are complex and time-consuming. The combination of the mass
spectrometer with the gas chromatograph impacts at this point, since each constituent
of the mixture can be identified almost immediately by passing the GC effluent into a
repetitively scanning mass spectrometer.
The technique of mass spectrometry (MS) rests on the observation that the ion
radical that is created when a compound is vaporized and exposed to an electron beam
in a near vacuum will disintegrate in a manner absolutely characteristic of its parent
compound [2]. The array of small fragments that is created constitutes the mass
spectrum, and the mass spectrometer is merely an instrument, albeit an extremely
complex and costly one, to create these fragments and to record their weights and
relative abundance. The ions are created in the source of the instrument and, in the
simplest case (low resolution), are accelerated and passed into a free-flight tube where
beams of different mass are separated by a magnetic field that deflects ions of lower
mass more than those of higher mass. The beams then impact on a recorder to produce
a "mass spectrum." More commonly, however, the strength of the magnetic field in
the free-flight tube is changed in a precisely controlled manner so that ion beams of one
mass after another pass through a narrow exit slit and impact on an ion photomultiplier
tube. In this instance, the output is a bar graph of photomultiplier tube response against
C

B
A

FIG. 1. -Gas chromatogram of trimethylsilyl derivatives of urine organic acids in a normal child; A
malonic acid (internal standard), B = urea, C = citric acid, D = hippuric acid, and E = C-24 paraffin
(external standard). Column packing: 5% OV-22 on 80/100 mesh Supelcoport (Supelco, Bellefonte, Pa.).
Carrier gas: nitrogen at 30 ml/min. Column temperature held at 800C for 4 min, increased to 280NC at
8TC/min, then held at 280'C for 4 min.
 GAS CHROMATOGRAPHY -MASS SPECTROMETRY 783
time, and time can be related to mass. The quadrupole instrument functions in much
the same way, except that ion beams are separated by changing direct and alternating
voltages on precisely contoured pole pieces (usually four) that surround the free-flight
path. In either case, however, the spectrum may be examined as it is generated, or it
may be stored for retrieval and examination at a more convenient time (fig. 2).
The modem mass spectrometer can generate a spectrum every 2 or 3 seconds, which
is easily fast enough to "catch" individual compounds as they are eluted from a gas
chromatograph. For example, the rapid and certain identification of the peak shown in
figure 3 as methylcitric acid allowed the diagnosis of propionic acidemia to be made in
an infant with ketotic hyperglycinemia, and for appropriate treatment and genetic
counseling to be given as well. Indeed, GC/MS has been crucial in developing our
current knowledge that ketotic hyperglycinemia, a syndrome characterized by
hyperglycinemia, neutropenia, thrombocytopenia, mental retardation, ketoacidosis,
and protein intolerance [3-5], can be caused by organic acidemias, and, in particular,
by propionic acidemia, methylmalonic acidemia, and 2-methyl-3-hydroxybutyric
acidemia. The cause of the syndrome, first described in 1961, was not clear until the
organic acidemias were discovered and these three particular ones were noted to share
many of its phenotypic features [6, 7].
Screening for Organic Acidemia
Organic acids accumulate in serum before being excreted in the urine but, since most
are poorly reabsorbed from the glomerular filtrate by the renal tubule, their urine
concentrations become much higher than those in serum and the organic acidemias are
more easily screened for when urine is examined. Accepted indications to screen for
these diseases are (1) an unusual odor, (2) metabolic acidosis, either persistent or

100
3-HYDROXYPROPIONIC ACID dITMS 147
CH2-0-Si(CH3)3
CH2

80- CO-0-Si(CH3)3 0ISi(CH3)3

CI
c Si(CH3)2

60 73
C
_ Sl(CH3)3 CH2-0-Si(CH3)3
C CH2-0-Si(CH3)3 CH2
* 40 ~0 ~ 1
~~~~~~~~~~I
CO-0-SI(CH3)2
* ~~~~~~~~~~~~~~~SKCH3)221
177

234
0
20 40 60 80 100 120 140 160 180 200 220 240
m/z (masa: charge ratio)
FIG. 2.-Mass spectrum of di-trimethylsilyl derivative of 3-hydroxypropionic acid, a metabolite excreted
in propionic acidemia, methylmalonic acidemia, and in severe biotin and cobalamin deficiency states,
together with probable structure of the major ions.
784 GOODMAN

FIG. 3. -Urine organic acids in a child with propionic acidemia; A = malonic acid (internal standard),
and B = C-24 paraffin (external standard). Crosshatched peak is due to methylcitric acid. (Gas
chromatographic conditions as detailed in fig. 1).

intermittent, and whether or not associated with an anion gap, (3) recurrent vomiting,
especially if associated with acidosis, (4) acute disease in infancy, especially if
associated with hyperammonemia or metabolic acidosis, and (5) progressive ex-
trapyramidal movement disorders in childhood. More debated indications include: (6)
Reye syndrome when recurrent, familial, or occurring in infancy, and (7) any inherited
disorder of obscure cause.
Screening of urine by GC can be performed in any laboratory and, if urine
concentration is corrected for, will exclude disease in 80% -90% of samples. Large
peaks in the remainder, although most often due to drugs, food additives, or normal
variation, will require their referral to a laboratory with GC/MS instrumentation and,
preferably, to one with enough experience examining organic acids that the spectra can
be interpreted rapidly. Several laboratories in North America and overseas, the
author's among them, now serve such a function, and their number is increasing as
familiarity with the technology increases and as the cost of the instrumentation is
brought down by advances in microprocessor and computer design.
THE ORGANIC ACIDEMIAS
Some information on nomenclature, metabolic block(s), and clinical and lab
diagnosis of the inherited organic acidemias is provided in table 1. Details about
genetics, pathogenesis, and treatment are provided in later sections.
GENETICS
Pedigree data and/or enzyme measurements on parents of affected patients have
established that most organic acidemias are inherited as autosomal recessive traits, but
in a few instances, for example, in methylmalonic acidemia due to the cbl D mutation
[41, 42] and some forms of glutaric acidemia type II [34], the pedigree data are too
scanty and knowledge of the primary defect too uncertain to exclude X-linked
inheritance. Whatever enzyme defects are known are demonstrable in cultured
 GAS CHROMATOGRAPHY -MASS SPECTROMETRY 785
fibroblasts, and in utero diagnosis based on enzyme studies in cultured amniotic cells
should be possible; to date, however, only fetuses with methylmalonic acidemia,
propionic acidemia, and glutaric acidemia have been diagnosed antenatally [43 -47].
Changes in amniotic fluid organic acids have been demonstrated in fetuses affected
with these three conditions and with pyroglutamic acidemia [44-49], but it would
appear prudent to base fetal diagnosis on enzyme assay until this approach has been
evaluated more fully.
Genetic heterogeneity has been studied extensively in methylmalonic acidemia and
propionic acidemia but not in other disorders, primarily because assay techniques are
not yet sensitive enough to detect complementation in somatic cell hybrids. Fibroblasts
from patients with methylmalonic acidemia can be divided into five complementation
groups, and the disorder can thus be caused by mutations in at least that number of
different loci. One complementation group, designated mut, contains mutations of the
methylmalonyl-CoA carbonylmutase apoenzyme, while the remaining four, termed
cbl A, cbl B, cbl C, and cbl D, are due to defects in the biosynthesis of
adenosylcobalamin, the mutase coenzyme [42, 50]. The defect in the cbl B group is in
ATP:cob(I)alamin adenosyltransferase [51]. While the defects in the other cbl groups
are not yet known, those in the cbl C and cbl D cells also compromise the synthesis of
methylcobalamin, the coenzyme for N5-methyltetrahydrofolate-homocysteine methyl-
transferase. The latter is one of two enzymes that remethylate homocysteine to
methionine, and methylcobalamin deficiency in these patients causes them to excrete
homocysteine as well as methylmalonic acid [31, 41].
The same complementation and assay techniques have been employed to divide
fibroblasts from patients with propionic acidemia into three groups: two (pcc A and pcc
C) in which the mutations may involve different subunits of propionyl-CoA apocar-
boxylase [52, 53] and one (bio) in which it presumably affects holocarboxylase
synthetase and leads to simultaneous deficiency of propionyl-CoA carboxylase,
3-methylcrotonyl-CoA carboxylase, and pyruvate carboxylase [54]. Propionyl-CoA
carboxylase activity is decreased appropriately in leukocytes and fibroblasts of obligate
carriers of the pcc A mutation but is normal in pcc C heterozygotes [46, 55].
PATHOGENESIS
There is much debate but little understanding about how the complex phenotype of
various inborn errors of metabolism derives from the primary gene defect, and this is
no less true of the organic acidemias than it is of such a long-known and extensively
studied disorder as phenylketonuria. The anion-gap metabolic acidosis and odors that
occur in some of these disorders are easy to explain, but it is considerably more difficult
to account for the episodes of vomiting, hepatomegaly, encephalopathy, and fatty
infiltration of the viscera that occur in many of them, and for the chronic degeneration
of the caudate and putamen that is seen in glutaric acidemia.
Vomiting, hepatomegaly, hyperammonemia, and encephalopathy are some of the
more consistent features of Reye syndrome, a disorder whose specific cause is
unknown but in which generalized mitochondrial dysfunction appears to play a role in
pathogenesis [56]. The obvious similarity of this disease to the episodes observed in
many organic acidemias has prompted examination of the effects of the accumulated
786 GOODMAN

u~~~~~~o

CU Cu ~~I0 u e
0

0 > ~ .0 .

bo
w

0 0 0 W ~
0-0c
co~
0
E

~~
j. ~ ~ ~~~0Z
Wu
'-
0 Cu
0 ~~~~~~~~~~~~0b
0 u.0 la0b*
Z 0 U,,~~~0 4- .C
Cu~~~~~~~~~u.
.0O 0..0 o
< .0
0.~~O
O 0O~r
... 0 4a>Clau
C

~ 0

Z 0 02 ~ ~ C
Cu~ ~ ~

.0

Q
00.0200
.4.)C
Z
- .0~~~~~~
Cu 0 ~~~~U
Cu 6.00

0~~ ~ ~ ~ ~ 0 >

cn 72 ' '
- C

.0
Cd

2 .0
GAS CHROMATOGRAPHY -MASS SPECTROMETRY 787

6-.J ~ ~ ~ ~ )

C) C

CU C

~~~~o~~~~~~~~~
o LL
0
0CU co
10
0U )) U .
( ) cis
~~ .~~~~C) ~~~~~
0 E C. CIS

(U 0 ~ ~ ~ ~ )0

C~~~~~~~~~~~~~~~~~~~~~~~~~~~~C

0 C
~~
*~~~0 CU V. ~0 N

0 C C)
0 4-101
Cla C~.
~

.0 0 6

002 C)00~~~~~~~~~~ ~ ~ 0

C)~~~~~~~~~~~~~~~~~~~~C

(U)enE -

(U E)
C)

>0U ~ . C 0 0
012 ~ 5
788 GOODMAN
metabolic intermediates on mitochondrial enzymes and/or function. Observations that:
(1) methylcitrate (which is accumulated in propionic acidemia and methylmalonic
acidemia) inhibits the citrate-malate shuttle as well as several enzymes of citrate and
isocitrate metabolism [57], (2) methylmalonic acid inhibits mitochondrial transport of
malate, 2-ketoglutarate, and isocitrate [58], (3) methylmalonyl-CoA inhibits pyruvate
carboxylase [59], and (4) propionate and isovalerate inhibit mitochondrial oxidation of
both pyruvate and 2-ketoglutarate [60] all support the notion that some of these
compounds may indeed be mitochondrial toxins. A unifying hypothesis to explain why
many of these disorders are so similar clinically has not, however, been put forward.
The cause of striatal degeneration in glutaric acidemia [61 ] is also obscure and may
be particularly important in understanding Huntington disease, a disorder in which the
distribution of lesions is remarkably similar. One possibility is that glutaric acid inhibits
the removal of glutamic acid from the synaptic cleft, causing overstimulation and
eventually death of the glutamatergic neurons which are especially abundant in the
striatum [62, 63].
TREATMENT
General measures used in the treatment of the organic acidemias include those aimed
at correcting dehydration, acidosis, hypoglycemia, and hyperammonemia during acute
episodes of vomiting and encephalopathy, as well as the use of drugs like sodium
valproate (Depakene) and the p-chlorophenyl analog of gamma-aminobutyric acid
(Lioresal) to treat the movement disorder of glutaric acidemia [64]. As in treating other
inborn errors, measures specific to particular disorders may be directed at: (1) reducing
the concentration of accumulated enzyme substrate, if it or a derivative is considered
toxic, (2) increasing the concentration of a necessary enzyme product, or (3) increasing
the activity of the mutant enzyme itself. All three approaches have been tried in these
conditions.
Efforts to reduce the concentration of enzyme substrate by reducing the intake of
protein or specific amino acids have been made in all but pyroglutamic acidemia. The
results have been good in isovaleric acidemia [65] but less encouraging in the other
disorders, where some patients do well [7, 22, 64, 66, 67] and some do not [68, 69,
and S. I. Goodman, unpublished observations]. Substrate reduction may also be
achieved, however, by providing alternate pathways for its disposal, and examples of
this approach include the treatment of patients with methylmalonic acidemia due to
cbl C and cbl D mutations with betaine, and of those with isovaleric acidemia with
glycine. In the first instance, betaine fuels the alternate route of homocysteine
remethylation (via betaine-homocysteine methyltransferase), but whether or not
lowering homocysteine accumulation in these patients affects the eventual outcome of
the condition is not yet clear (S. I. Goodman, unpublished observations). In isovaleric
acidemia, however, where glycine apparently reduces isovaleryl-CoA accumulation by
increasing its conversion to isovalerylglycine, the acute episodes that usually occur
with intercurrent infection or protein loads become far less severe and frequent [70].
Where deficiency of enzyme product is the critical problem, as it is in patients with
methylmalonic acidemia due to blocks in adenosylcobalamin synthesis (cbl mutants),
two approaches have been tried. In the cbl mutants, for example, the block might be
 GAS CHROMATOGRAPHY -MASS SPECTROMETRY 789
bypassed by direct administration of adenosylcobalamin or its synthesis might be
increased by providing enough vitamin B12 so that the mutant enzyme, presumably a
Km mutant in which enzyme-substrate interaction is impaired, will be exposed to more
substrate and will thus form more product. Some of these patients respond to
adenosylcobalamin [71], but cyano- and hydroxycobalamin are so much cheaper and
easier to obtain that treatment usually takes the latter approach [72, 73] and, when
successful, allows protein restriction to be eased considerably. Similarly, when large
quantities of biotin (about 10 mg/day) are given to patients with combined carboxylase
deficiency, enough biotin is evidently processed (even in the face of the block) to
normalize tissue carboxylase activities [74].
The above situations show how enzyme activity, as judged by the rate of product
formation, can be increased by providing a Km mutant enzyme with additional
substrate; in some cases, however, the mutation is such that activity can be boosted by
providing it with additional coenzyme. For example, some mut methylmalonic
acidemia fibroblasts increase their apomutase activity when grown in medium
supplemented with hydroxocobalamin [75], presumably because the mutation de-
creases the interaction of enzyme and adenosylcobalamin rather than that of enzyme
and substrate. No patient with a mut defect, has, however, been responsive in vivo, not
even those whose fibroblasts respond to cobalamin in vitro.

REFERENCES
1. McNAIR HM, BONELLI EJ: Basic Gas Chromatography, 5th ed. Walnut Creek, Calif.,
Varian Aerograph, 1969
2. LIGON WV: Molecular analysis by mass spectrometry. Science 205:151 -159, 1979
3. CHILDs B, NYHAN WL, BORDEN MA, BARD L, COOKE RE: Idiopathic hyperglycinemia
and hyperglycinuria, a new disorder of amino acid metabolism. Pediatrics 27:522-538,
1961
4. NYHAN WL, BORDEN 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 27:539-550, 1961
5. CHILDS B, NYHAN WL: Further observations of a patient with hyperglycinemia. Pediatrics
33:403-412, 1964
6. ROSENBERG LE, LILLJEQVIsT A, HSIA YE: Methylmalonic aciduria: an inborn error leading
to metabolic acidosis, long-chain ketonuria and intermittent hyperglycinemia. N Engl J
Med 278:1319- 1322, 1968
7. HILLMAN RE, KEATING JP: Beta-ketothiolase deficiency as a cause of the "ketotic
hyperglycinemia syndrome." Pediatrics 53:221-225, 1974
8. TANAKA K, BUDD MA, EFRON ML, ISSELBACHER K: Isovaleric acidemia: a new genetic
defect of leucine metabolism. Proc Nati Acad Sci (USA) 56:236-242, 1966
9. BUDD MA, TANAKA K, HOLMES LB, EFRON ML, CRAWFORD JD, ISSELBACHER KJ:
Isovaleric acidemia: clinical features of a new genetic defect of leucine metabolism. N Engl
J Med 277:321 - 327, 1967
10. RHEAD W, TANAKA K: Demonstration of mitochondrial isovaleryl-CoA dehydrogenase
deficiency in fibroblasts from patients with isovaleric acidemia by a tritium release assay.
Am JHum Genet 30:38A, 1978
11. TANAKA K, ISSELBACHER KJ: The isolation and identification of N-isovalerylglycine from
urine of patients with isovaleric acidemia. J Biol Chem 242:2966-2972, 1967
12. TANAKA K, ORR JC, ISSELBACHER KJ: Identification of /8-hydroxyisovaleric acid in the
urine of a patient with isovaleric acidemia. Biochim Biophys Acta 152:638-641, 1968
790 GOODMAN
13. ELDJARN L, JELLUM E, STOKKE 0, PANDE H, WAALER PE: /8-Hydroxyisovaleric aciduria
and f-methylcrotonylglycinuria: a new inborn error of metabolism. Lancet 2:521-522,
1970
14. GOMPERTZ D, GOODEY PA, BARTLETT K: Evidence for the enzymic defect in 13-methyl-
crotonylglycinuria. FEBS Lett 32:13 -14, 1973
15. BARTLETT K, GOMPERTZ D: Combined carboxylase defect: biotin responsiveness in
cultured fibroblasts. Lancet 2:804, 1976
16. SWEETMAN L, BATES SP, HULL D, NYHAN WL: Propionyl-CoA carboxylase deficiency in
a patient with biotin-responsive 3-methylcrotonylglycinuria. Pediatr Res 11:1 144- 1147,
1977
17. FAULL K, BOLTON P, HALPERN B, ET AL.: Patient with defective leucine metabolism. N
Engl J Med 294:1013, 1976
18. WYSOCKI SJ, HAHNEL R: 3-Hydroxy-3-methylglutaric aciduria: deficiency of 3-hydroxy-
3-methylglutaryl coenzyme A lyase. Clin Chim Acta 71:349-351, 1976
19. FAULL KF, BOLTON PD, HALPERN B, HAMMOND J, DANKS DM: The urinary organic acid
profile associated with 3-hydroxy-3-methylglutaric aciduria. Clin Chim Acta 73:553 -559,
1976
20. DURAN M, KETTING D, WADMAN SK, JACOBS C, SCHUTGENS RBH, VEDER HA: Organic
acid excretion in a patient with 3-hydroxy-3-methylglutaryl-CoA Iyase deficiency; facts and
artifacts. Clin Chim Acta 90:187 - 193, 1978
21. DAUM RS, SCRIVER CR, MAMER OA, DELVIN E, LAMM P, GOLDMAN H: An inherited
disorder of isoleucine catabolism causing accumulation of a-methylacetoacetate and
a-methyl-f8-hydroxybutyrate, and intermittent metabolic acidosis. Pediatr Res 7:149-160,
1973
22. GOMPERTZ D, SAUDUBRAY JM, CHARPENTIER C, BARTLETT K, GOODEY PA, DRAFFAN
GH: A defect in L-isoleucine metabolism associated with a-methyl-/8-hydroxybutyric and
a-methylacetoacetic aciduria: quantitative in vivo and in vitro studies. Clin Chim Acta
57:269-281, 1974
23. HOMMES FA, KUIPERS JRG, ELEMA JD, JANSEN JF, JONXIS JHP: Propionic acidemia, a
new inborn error of metabolism. Pediatr Res 2:519 - 524, 1968
24. HSIA YE, SKULLY KJ, ROSENBERG LE: Inherited propionyl-CoA carboxylase deficiency in
"ketotic hyperglycinemia. " J Clin Invest 50:127 - 130, 1971
25. WOLF B, PAULSEN EP, HSIA YE: Asymptomatic propionyl CoA carboxylase deficiency in a
13-year-old girl. J Pediatr 95:563 - 565, 1979
26. ANDO T, RASMUSSEN K, NYHAN WL, HULL D: 3-Hydroxypropionate: significance of
,8-oxidation of propionate in patients with propionic acidemia and methylmalonic acidemia.
Proc NatlAcadSci (USA) 69:2807-2811, 1972
27. ANDO T, RASMUSSEN K, WRIGHT JM, NYHAN WL: Isolation and identification of
methylcitrate, a major metabolic product of propionate in patients with propionic acidemia.
J Biol Chem 247:2200 - 2204, 1972
28. STOKKE 0, ELDJARN L, NORUM KR, STEEN-JOHNSEN J, HALVORSEN S: Methylmalonic
aciduria: a new inborn error of metabolism which may cause fatal acidosis in the neonatal
period. Scand J Clin Lab Invest 20:313 - 328, 1967
29. OBERHOLZER VG, LEVIN B, BURGESS EA, YOUNG WF: Methylmalonic aciduria: an inborn
error of metabolism leading to chronic metabolic acidosis. Arch Dis Child 42:492-504,
1967
30. MORROW G, BARNESS LA, CARDINALE GJ, ABELES RH, FLAKS JG: Congenital methyl-
malonic acidemia: enzymatic evidence for two forms of the disease. Proc Natl Acad Sci
(USA) 63:191-197, 1969
31. LEVY HL, MUDD SH, SCHULMAN JD, DREYFUS PM, ABELES RH: A derangement in B12
metabolism associated with homocystinemia, cystathioninemia, hypomethioninemia, and
methylmalonic aciduria. Am J Med 48:390 - 397, 1970
32. GOODMAN SI, MARKEY SP, MOE PG, MILES BS, TENG CC: Glutaric aciduria: a "new
disorder of amino acid metabolism. Biochem Med 12:12-21, 1975
 GAS CHROMATOGRAPHY -MASS SPECTROMETRY 791
33. STOKKE 0, GOODMAN SI, THOMPSON JA, MILES BS: Glutaric aciduria: presence of
glutaconic and ,B-hydroxyglutaric acids in urine. Biochem Med 12:386-391, 1975
34. PRZYREMBEL H, WENDEL U, BECKER K, ET AL.: Glutaric aciduria type II: report on a
previously undescribed metabolic disorder. Clin Chim Acta 66:227-239, 1976
35. MANTAGOS S, GENEL M, TANAKA K: Ethylmalonic-adipic aciduria: in vivo and in vitro
studies indicating deficiency of activities of multiple acyl-CoA dehydrogenases. J Clin
Invest 64:1580 - 1589, 1979
36. GOODMAN SI, MCCABE ERB, FENNESSEY PV, MACE JW: Multiple acyl-CoA dehydro-
genase deficiency (glutaric aciduria type II) with hypersarcosinemia and sarcosinuria:
possible inherited deficiency of an electron transfer flavoprotein. Pediatr Res 14:12 - 17,
1980
37. DuSHEIKo G, KEW MC, JOFFE BI, LEWIN JR, MANTAGOS S, TANAKA K: Recurrent
hypoglycemia associated with glutaric aciduria type II in an adult. N Engl J Med
301:1405-1409, 1979
38. JELLUM E, KLUGE T, BORRESON HC, STOKKE 0, ELDJARN L: Pyroglutamic aciduria -a
new inborn error of metabolism. Scand J Clin Lab Invest 26:327 -335, 1970
39. WELLNER VP, SEKURA R, MEISTER A, LARSSON A: Glutathione synthetase deficiency, an
inborn error of metabolism involving the y-glutamyl cycle in patients with 5-oxoprolinuria
(pyroglutamic aciduria). Proc Natl Acad Sci (USA) 71:2505-2509, 1974
40. BRANDT NJ, RASMUSSEN K, BRANDT S, K0LVRAA S, SCH0NHEYDER F: D-Glyceric-
acidaemia and non-ketotic hyperglycinaemia. Acta Paediatr Scand 65:17 -22, 1976
41. GOODMAN SI, MOE PG, HAMMOND KB, MUDD SH, UHLENDORF BW: Homocystinuria
with methylmalonic aciduria: two cases in a sibship. Biochem Med 4:500-515, 1970
42. WILLARD HF, MELLMAN IS, ROSENBERG LE: Genetic complementation among inherited
deficiencies of methylmalonyl-CoA mutase activity: evidence for a new class of human
cobalamin mutant. Am J Hum Genet 31:1-13, 1978
43. MORROW G, SCHWARZ RH, HALLOCK JA, BARNESS LA: Prenatal detection of methyl-
malonic acidemia. J Pediatr 77:120 - 123, 1970
44. MAHONEY MJ, ROSENBERG LE, LINDBLAD B, WALDENSTROM J, ZETTERSTROM R: Prenatal
diagnosis of methylmalonic aciduria. Acta Paediatr Scand 64:44-48, 1975
45. AMPOLA MG, MAHONEY MJ, NAKAMURA E, TANAKA K: Prenatal therapy of a patient with
vitamin B12-responsive methylmalonic acidemia. N Engl J Med 293:313-317, 1975
46. GOMPERTZ D, GOODEY PA, THOM H, ET AL.: Prenatal diagnosis and family studies in a
case of propionicacidaemia. Clin Genet 8:244-250, 1975
47. GOODMAN SI, GALLEGOS DA, PULLIN CJ, ET AL.: Antenatal diagnosis of glutaric
acidemia. Am J Hum Genet 32:695 -699, 1980
48. LARSSON A, ZETTERSTROM R, HAGENFELDT L, ANDERSON R, DREBURG S, HORNELL H:
Pyroglutamic aciduria (5-oxoprolinuria), an inborn error in glutathione metabolism.
Pediatr Res 8:852 - 856, 1974
49. SWEETMAN L, WEYLER W, SHAFAI T, YOUNG PE, NYHAN WL: Prenatal diagnosis of
propionic acidemia by organic acid analysis. Clin Res 24:295A, 1976
50. GRAVEL RA, MAHONEY MJ, RUDDLE FH, ROSENBERG LE: Genetic complementation in
heterokaryons of human fibroblasts defective in cobalamin metabolism. Proc Natl Acad Sci
(USA) 72:3181 -3185, 1975
51. FENTON WA, ROSENBERG LE: Genetic and biochemical analysis of human cobalamin
mutants in cell culture. Annu Rev Genet 12:223-248, 1978
52. GRAVEL RA, LAM KF, SKULLY KJ, HSIA YE: Genetic complementation of propionyl-CoA
carboxylase deficiency in cultured human fibroblasts. Am JHum Genet 29:378-388, 1977
53. WOLF B, HSIA YE, ROSENBERG LE: Biochemical differences between mutant propionyl-
CoA carboxylases from two complementation groups. Am J Hum Genet 30:455-464, 1978
54. SWEETMAN L, PACKMAN S, YOSHINO M, ET AL.: Biotin responsive multiple carboxylase
deficiency (abstr.). Pediatr Res 13:426, 1979
55. WOLF B, ROSENBERG LE: Heterozygote expression in propionyl-CoA carboxylase de-
ficiency. J Clin Invest 62:931 -936, 1978
792 GOODMAN
56. DEVIvO DC: Reye syndrome: a metabolic response to an acute mitochondrial insult?
Neurology 28:105-108, 1978
57. CHEEMA-DHADLI S, LEZNOFF CC, HALPERIN ML: Effect of 2-methylcitrate on citrate
metabolism: implications for the management of patients with propionic acidemia and
methylmalonic aciduria. Pediatr Res 9:905 - 908, 1975
58. HALPERIN ML, SCHILLER CM, FRITZ IB: The inhibition by methylmalonic acid of malate
transport by the dicarboxylate carrier in rat liver mitochondria. J Clin Invest 50:2276-
2282, 1971
59. UTTER MF, KEECH DB, SCRUTTON MC: A possible role for acetyl-CoA in the control of
gluconeogenesis, in Advances in Enzyme Regulation, vol 2, edited by WEBER G, New
York, Pergamon, 1964, pp 49 - 68
60. GREGERSEN N: Studies on the effects of saturated and unsaturated short-chain monocar-
boxylic acids on the energy metabolism of rat liver mitochondria. Pediatr Res 13:1227 -
1230, 1979
61. GOODMAN SI, NORENBERG MD, SHIKES RH, BRESLICH DJ, MOE PG: Glutaric aciduria:
biochemical and morphologic considerations. J Pediatr 90:746 -750, 1977
62. SIMON JR, CONTRERA JF, KUHAR MJ: Binding of (3H)kainic acid, an analogue to
L-glutamate, to brain membranes. J Neurochem 26:141 - 147, 1976
63. HERNDON RM, COYLE JT: Selective destruction of neurons by a transmitter agonist.
Science 198:71 -72, 1977
64. BRANDT NJ, GREGERSEN N, CHRISTENSEN E, GR0N IH, RASMUSSEN K: Treatment of
glutaryl-CoA dehydrogenase deficiency (glutaric aciduria): experience with diet, riboflavin
and GABA analogue. J Pediatr 94:669-673, 1979
65. LEVY HL, ERICKSON AM, LOTT IT, KURTZ DJ: Isovaleric acidemia: results of family study
and dietary treatment. Pediatrics 52:83 -94, 1973
66. BRANDT IK, HSIA YE, CLEMENT DH, PROVENCE SA: Propionicacidemia (ketotic
hyperglycinemia): dietary treatment resulting in normal growth and development. Pediat-
rics 53:391 -395, 1974
67. NYHAN WL, FAWCETT N, ANDO T, RENNERT 0, JULIUS RL: Response to dietary therapy
in B12 unresponsive methylmalonic acidemia. Pediatrics 51:539-548, 1973
68. STOKKE 0, ELDJARN L, JELLUM E, PANDE H, WAALER PE: Beta-methylcrotonyl-CoA
carboxylase deficiency: a new metabolic error in leucine degradation. Pediatrics 49:726-
735, 1972
69. DURAN M, BRUINvIS L, KETTING D, WADMAN SK: Deranged isoleucine metabolism
during ketotic attacks in patients with methylmalonic acidemia. J Inher Metab Disord
1:105-107, 1978
70. YUDKOFF M, COHN RM, PUSCHAK R, ROTHMAN R, SEGAL S: Glycine therapy in isovaleric
acidemia. J Pediatr 92:813 - 817, 1978
71. LINDBLAD B, LINDSTRAND K, SVANBERG B, ZETTERSTROM R: The effect of cobamide
coenzyme in methylmalonic acidemia. Acta Paediatr Scand 58:178 - 180, 1969
72. ROSENBERG LE, LILLJEQVIST AC, HSIA YE: Methylmalonic aciduria: metabolic block
localization and vitamin B12 dependency. Science 162:805 -807, 1968
73. GOODMAN SI, KEYSER AJ, MUDD SH, SCHULMAN JD, TURSE H, LEWY J: Responsiveness
of congenital methylmalonic aciduria to derivatives of vitamin B12 (abstr.). Pediatr Res
6:138, 1972
74. GOMPERTZ D, DRAFFAN GH, WATTS JL, HULL D: Biotin-responsive f3-methylcrotonyl-
glycinuria. Lancet 2:22-24, 1971
75. WILLARD HF, ROSENBERG LE: Inherited deficiencies of methylmalonyl CoA mutase
activity: reduced affinity of mutant apoenzyme for adenosylcobalamin. Biochem Biophys
Res Commun 78:927 - 934, 1977