Reid, ES; (2016) Cellular and molecular investigations of undiagnosed neurometabolic disorders. Doctoral thesis , UCL (University College London).

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Abstract

Inborn errors of metabolism (IEM) affect 1 in 500 newborns causing significant disease-burden and mortality throughout childhood. However, despite extensive genetic and biochemical investigations the cause of disease remains unknown in up to 50% of patients with neurological symptoms; so-called neurometabolic disorders (NMD). The overarching aim of this thesis was to determine the cellular and molecular aetiologies for the clinical phenotypes seen in patients with undiagnosed NMD. In order to improve the diagnosis of these disorders in clinical practice, a comprehensive targeted gene panel of 614 genes known to cause IEM was designed and a cohort of 44 patients was analysed. A definitive or probable genetic diagnosis was achieved in 53% of patients without a prior genetic diagnosis. Method optimisation and validation, comparison to other diagnostic strategies and the advantages and disadvantages of targeted sequencing are reviewed. Case reports, novel mutations/phenotypes and their contribution to the expansion of the literature are described. Whole exome sequencing and functional characterisation was also undertaken for patients who had been extensively clinically investigated previously. Five patients identified with mutations in the mitochondrial glutamate transporter, SLC25A22, presenting with novel biochemical phenotypes are described and novel transporter functions are postulated. One patient diagnosed with a potassium channelopathy with biochemical abnormalities and anticonvulsant responses suggestive of an inborn error of vitmain B6 metabolism is documented and the mechanisms underlying the generalised anticonvulsant effects of vitamin B6 are postulated. Characterisation of a possible novel inborn error of lysine metabolism in a patient presenting with hyperlysinaemia and motor neuron disease is also discussed. These studies also demonstrate the complexity of unravelling the relationship between genotype and phenotype and highlight the need for novel functional assays to assess the pathogenicity of sequence variants. Mass spectrometry-based assays were developed to enable characterisation of disorders affecting vitamin B6 homeostasis, including pyridox(am)ine 5'-phosphate oxidase (PNPO), antiquitin and PROSC deficiency, the latter being a novel disorder. The differences between pyridoxine- and pyridoxal phosphate-responsive PNPO deficiency and fibroblast vitamer profiles in all patients were all investigated. Finally, multiple methodologies were employed with the aim of understanding the biological function of PROSC.

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