Phenylketonuria in Hong Kong Chinese: a call for hyperphenylalaninemia newborn screening in the Special Administrative Region, China Chloe

Miu Mak, Chun-hung Ko, Ching-wan Lam, Wai-ling Lau, Wai-kwan Siu, Sammy Pak-lam Chen, Chun-yiu Law, Chi-kong Lai, Chak-man Yu, Albert Yan-wo Chan Abstract: Hyperphenylalaninemia is one of the commonest inborn errors of metabolism affecting approximately 1 in 15000 live births. Among Chinese, BH4 deficiency leading to hyperphenylalaninemia is much commoner than in Caucasians. Exact diagnosis is important for the treatment and genetic counseling. In 2000, newborn screening for phenylketonuria is mandatory by law in China throughout the whole country. However, it is not yet included in the newborn screening program of the Hong Kong Special Administrative Region, China. Published data on hyperphenylalaninemia among Hong Kong Chinese are largely lacking. We report a 1-year-old Hong Kong Chinese girl with severe 6-pyruvoyl-tetrahydropterin synthase (PTPS) deficiency. The patient presented with infantile hypotonia and was misdiagnosed as cerebral palsy. She had very mild hyperphenylalaninemia (95 mol/L), significantly high phenylalnine-to-tyrosine ratio (3.1), and elevated prolactin of 1109 mIU/L. Genetic analysis confirmed a homozygous known disease-causing mutation PTS NM_000317.1: c.259C>T; NP_000308.1: p.P87S in the proband. In our local experience, while the estimated prevalence of hyperphenylalaninemia due to PTPS deficiency was reported to be 1 in 29542 live births, not a single case of phenylalanine hydroxylase deficiency has been reported. Furthermore, there is a general lack of awareness of inherited metabolic diseases in the community as well as among the medical professionals. Very often, a low index of clinical suspicion will lead to delay in diagnosis, multiple unnecessary and costly investigations, prolonged morbidity and anxiety to the family affected. We strongly recommend that expanded newborn screening for hyperphenylalaninemia should be implemented for every baby born in the Hong Kong Special Administrative Region, China. The disease named phenylketonuria (PKU) is familiar to almost every medical student and doctor. The first description of PKU and its linkage to mental retardation was reported in 1934 (http://www.pku.com/what-is-pku/ history-ofphenylketonuria.php). The enzyme defect of classical PKU is the phenylalanine hydroxylase (PAH). Subsequently, the term PKU is known to include more complex etiologies with at least four more enzymatic defects affecting the tetrahydrobiopterin (BH4) synthetic pathway. They are deficiencies of GTP cyclohydrolase, 6-pyruvoyltetrahydropterin synthetase (PTPS), pterin-4acarbinolamine dehydratase and dihydropteridine reductase. All of them can cause the same biochemical abnormalities of elevated phenylalanine and phenylketonuria as classical PKU with similar clinical presentations. They are sometimes called as atypical PKU or non-PKU hyperphenylalaninemia. Distinguishing patients with BH4-deficient variants from classical PKU (PAH deficiency) is crucial for specific treatment and prognosis. Hyperphenylalaninemia is a panethnic disorder affecting approximately 1 in 15000 live births. In mainland China, the incidence ranges from 1 in 11000 (Beijing), 1 in 17000 (Shanghai) to 1 in 29000 (Guangzhou).1 Newborn screening for hyperphenylalaninemia is one of the most successful screening programs in the history. In western countries, nationalwide newborn screening for PKU has been implemented for more than four decades with impressive cost effectiveness and promising outcome as a preventive medicine measure. In 2000, newborn screening for phenylketonuria is mandatory by law in China throughout the whole country.2 However, it is not yet included in the newborn screening program of the Hong Kong Special Administrative Region (SAR), China. Among the Hong Kong Chinese, PTPS deficiency is much more common than PAH deficiency. While the estimated prevalence of hyperphenylalaninemia due to PTPS deficiency was reported to be 1 in 29542 live births,3 not a single case of PAH deficiency has been reported. Furthermore, there is a general lack of awareness of inborn errors of metabolism inherited metabolic diseases in the community and among the medical professionals. Very often, a low index of clinical suspicion will lead to delay in diagnosis, multiple unnecessary and costly investigations, prolonged morbidity and anxiety to the family affected. The first patients of atypical PKU due to BH4 deficiency were reported independently by Bartholom4 and Smith and Lloyd5 in 1974 respectively. Incidence of BH4 deficiency is considerably higher in Chinese especially Southern Chinese than in Caucasians.6 Among BH4 deficiency hyperphenylalaninemias, PTPS deficiency is the commonest type. Up to date, there are 350 patients of PTPS deficiency registered in the International BIODEF Database (accessed on 11 September 2010).7 Sixty-one of them were Chinese and four were Hong Kong Chinese patients suffered from severe form of PTPS deficiency with significant hyperphenylalaninemia greater than 600 mmol/L. However, there is no published literature about these cases. Here, we report a Hong Kong Chinese patient with

severe PTPS deficiency yet associated with very mild hyperphenylalaninemia. The patient was misdiagnosed as cerebral palsy. DISCUSSION We present a unique case of severe PTPS deficiency associated with mildly increased plasma phenylalanine levels first recognized at 11 months of age. The patient was homozygous for PTS NM_000317.1: c.259C>T; NP_000308.1: p.P87S which is known to be associated with severe PTPS deficiency.8 Mutation p.P87S is a founder mutation commonly seen in Taiwanese, China.9 It reduces the PTPS enzyme activity to 52% on expression studies.8 Interestingly, plasma phenylalanine concentration correlates neither with the genotype nor clinical severity. Imamura et al8 reported two patients sharing the same homozygous p.P87S as our patient but their plasma phenylalanine levels were remarkably higher (one 2-week-old patient of 1550 mmol/L and another 7-monthold of 1580 mmol/L). Low phenylalanine level per se does not protect patients from severe neurological damage of the disease, probably also due to the detrimental effects on the synthesis of neurotransmitters. Apart from normal plasma phenylalanine concentrations, patients with PTPS deficiency can manifest with atypical biochemical pictures. Cerebrospinal fluid (CSF) neurotransmitters measurement can also appear normal in the first month of life and decrease later as the child grows at 12 years old.10-12 Moreover, with normal or mildly elevated plasma phenylalanine levels, urinary phenylalanine (by amino acid profile) and urinary phenylketonuria (by organic acid profile or ferric chloride and 4dinitrophenylhydrazine spot tests) could be negative. It is important to note that our patient showed abnormal phenylalanine-to-tyrosine ratio (95/31 = 3.1 and 129/53 = 2.4) despite a very marginally increased plasma phenylalanine at 11 and 12 months old respectively. Chace et al13 described the use of phenylalanine- to-tyrosine ratio with a cutoff of 2.5 to improve the diagnostic accuracy of hyperphenylalaninemia in newborn screening. Normal subjects usually have a median molar ratio around 0.73. In order to minimize both false positive and false negatives in the picking up hyperphenylalaninemias due to BH4 deficiency, regardless of the initial plasma phenylalanine level, use of multiple diagnostic parameters would be helpful, such as the phenylalanine-to-tyrosine ratio, measurements of pterins14 and genetic screening for prevalent mutations. Our patient presented with infantile floppiness and hypotonia. Hypotonia is a very common but nonspecific symptom in sick infants with too many metabolic as well as non-metabolic differential diagnoses. Without newborn screening for hyperphenylalaninemia, the diagnostic pathway of infantile hypotonia is often complicated, requiring numerous investigations such as chromosomal study for Prader Willi syndrome and other syndromes, nerve conduction and other electrophysiology studies, MRI brain and other radiological imaging for structural CNS defects, plasma lactate for mitochondrial disorders, very long chain fatty acid measurement for peroxisomal disorders, lysosomal enzyme screen and urine oligosaccharides for lysosomal storage disorders, transferin pattern by isoelectric focusing for congenital disorders of glycosylation, and some invasive procedures like muscle biopsy and CSF analysis. At times, referral to other specialist centre with longer appointment waiting time may further delay the diagnosis and treatment leading to poorer prognosis. In our patient, with the infantile hypotonia, elevated prolactin and phenylalanine, genetic analysis was provided promptly to simplify the diagnostic work up and achieve earlier treatment. Hyperphenylalaninemia is the commonest inborn errors of metabolism in expanded newborn screening. In China, it is mandatorily screened in all provinces throughout the whole country.2 It is generally accepted that this public health measure is costeffective and various issues such as patient outcome, social and ethical issues have all been thoroughly documented. It is logical to expect the extension of such a newborn screening program to Hong Kong will achieve the same benefits. In addition, since Hong Kong is an international metropolis with various ethnic populations living in, a comprehensive newborn screening program and/or referral system is definitely required to accommodate different public healthcare needs of Caucasians, mainland Chinese, Hong Kong Chinese as well as people from other ethnicities. Intervention upstream is better than downstream. This is reflected by the experience from Taiwan, China, where hyperphenylalaninemia accounts for 1 in 1581 mentally retarded school-aged children.15 The yield of downstream screening for hyperphenylalaninemia among high-risk groups will be much higher, but it might be too late for these patients to realize the full benefit of treatment.