A RARELY SEEN UREA CYCLE DEFECT:
CITRULINEMIA
Sonmez OE1, Hatipoglu
S1, Cetin BD2, Aksu K1
1 Department of Pediatrics
2 Department of Clinical Microbiology and Infectious Diseases
Sisli Etfal Training and Research Hospital, Istanbul, Turkey
The free ammonia
produced by the catabolism of aminoacids is detoxifed to urea through
reactions that are catalyzed by urea cycle enzymes the affected children
usually become symptomatic with vomiting, tachypnea, lehtargy progressing
to a deep coma and convulsions after a few days of protein feeding. A
18-months old female patient was hospitalized in our department with
clinical manifestations of vomiting, ataxia, mental confusions, agitation,
irritability and combativeness. She had a sister who had died in neonatal
period and undiagnosed. Her father and mother were cousins. Physical
examination revealed lethargy, somnolence progressing to coma. Bileteral
light reflexes were positive, pupils were isocoric. There were no meningeal
irritation signs. She had hepatomegaly. Laboratory studies showed AST: 476
IU/L ALT: 1763 IU/L LDH: 1085 U/L ALP: 1020 U/L, PT: 20 sec. PTT: 40 sec.,
Protrombin activity: %50, BUN: 5 mg/dL. Serum concentration of bicarbonate
and pH were normal. Hepatic markers were negative. Plasma ammonia nitrogen
levels were high (400 mmol/l). Lumbar puncture results revealed no cell in
CSF, normal biochemical findings and culture remained sterile. No spesific
finding in urine analysis were found. While searching plasma aminoacid
levels plasma citrulline levels were found high. (500 mmol/L). The clinical
symptoms of our breast feeding infant were in silence in subacute
citrullinemia. After begining the diet that contains higher protein, she
had vigorous clinical progress a hyperammonemia that needs urgent diagnosis
and therapy. In differentiating major causes of metabolic encephalopathy,
especially if there is a history of death in the neonatal period in the
family (inherited autosomal recessive trait), diagnosis of urea cycle
defects that require urgent spesific laboratory studies should be
investigated.