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Very Long Chain Acyl CoA Dehydrogenase Deficiency (LCAD)

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Copyright 1996, 1998, 2001, 2004, 2010, 2013

NORD is very grateful to Jerry Vockley, MD, PhD, University of Pittsburgh, Chief of Medical Genetics, Children's Hospital of Pittsburgh of UPMC, for assistance in the preparation of this report.

Synonyms of Very Long Chain Acyl CoA Dehydrogenase Deficiency (LCAD)

Disorder Subdivisions

General Discussion

Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD) is a rare genetic disorder of fatty acid metabolism that is transmitted as an autosomal recessive trait. It occurs when an enzyme needed to break down certain very long-chain fatty acids is missing or not working properly. VLCAD is one of the metabolic diseases known as fatty acid oxidation (FOD) diseases. In the past, the name long-chain acyl-CoA dehydrogenase deficiency (LCAD) was applied to one such disease, but today it is clear that all cases once thought to be LCAD are actually VLCAD.

The breakdown of fatty acids takes place in the mitochondria found in each cell. The mitochondria are small, well-defined bodies that are found in the cytoplasm of cells and in which the body generates energy from the breakdown of complex substances into simpler ones (mitochondrial oxidation).

Classically, two forms of VLCAD have been described: an early-onset, severe form which, if unrecognized and undiagnosed, may lead to extreme weakness of the heart muscles (cardiomyopathy) and may be life-threatening (VLCAD-C), and a later-onset, milder form, sometimes referred to as VLCAD-H, that is characterized by repeated bouts of low blood sugar (hypoglycemia). In reality, patients may present with a combination of symptoms and the disease is best though of as being a continuum. Since the advent of expanded newborn screening programs using tandem mass spectrometry technology, most VLCAD infants in the United States are being detected neonatal period.

Symptoms

Children with early-onset VLCAD-C present with symptoms within days or weeks after birth. These infants also show signs of low blood sugar (hypoglycemia), irritability and listlessness (lethargy). From ages two or three months to about two years, infants with this form of the disorder will be at risk for thickening of the heart muscles (hypertrophic cardiomyopathy), abnormal heart rhythms and cardiorespiratory failure.

Later-onset VLCAD-H may present with recurrent episodes of lethargy and even coma associated with low blood sugar during infancy and a noticeably enlarged liver (hepatomegaly) during childhood. During later childhood and early adulthood, the patient hypoglycemia becomes less common and patients instead experiences periodic attacks muscle pain and breakdown (rhabdomyolysis).

The hypoglycemia associated with each form occurs with little or no accumulation of ketone bodies (hypoketotic hypoglycemia) in the blood. (Ketone bodies are chemical substances normally produced by fatty acid metabolism in the liver.) There are very complicated patterns of blood chemicals and concentrations of unusual acids in the blood. A patient’s blood will be examined for these patterns if VLCAD is suspected.
Affected individuals may begin to experience recurrent increased acid levels in blood and body tissues (metabolic acidosis); sudden cessation of breathing (respiratory arrest) and even cardiac arrest. These symptoms may be associated with cardiomyopathy [see below]); listlessness, severe drowsiness (lethargy), and coma. Without prompt, appropriate treatment, such acute episodes may lead to potentially life-threatening complications. (For further information, please see Standard Therapies below.)

Individuals with VLCAD deficiency may have fat deposits (fatty infiltration) and abnormal enlargement of the liver (hepatomegaly); poor muscle tone (hypotonia); and/or evidence of cardiomyopathy. For example, there may be abnormal thickening (hypertrophy) or stretching and enlargement (dilation) of the left lower chamber (ventricle) of the heart (i.e., hypertrophic or dilated cardiomyopathy). Cardiomyopathy may lead to weakening in the force of heart contractions, decreased efficiency in the circulation of blood through the lungs and to the rest of the body (heart failure), and various associated symptoms that may depend upon the nature and severity of the condition, patient age, and other factors.

Causes

Very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency is an autosomal recessive condition. Human traits, including the classic genetic diseases, are the product of the interaction of two genes, one received from the father and one from the mother.
The gene for VLCAD (ACADVL) is found at gene map locus 17p11.2-p11.1. Original reports of long chain Acyl-CoA dehydrogenase deficiency (LCAD) in the literature were in error and all previously published cases of LCAD deficiency have been shown to be VLCAD deficiency.

Chromosomes, which are present in the nucleus of human cells, carry the genetic information for each individual. Human body cells normally have 46 chromosomes. Pairs of human chromosomes are numbered from 1 through 22, and the sex chromosomes are designated X and Y. Males have one X and one Y chromosome and females have two X chromosomes. Each chromosome has a short arm designated "p" and a long arm designated "q". Chromosomes are further sub-divided into many bands that are numbered. For example, "chromosome 17p11.2-p11.1" refers to a region between bands 11.2 and 11.1 on the short arm of chromosome 17. The numbered bands specify the location of the thousands of genes that are present on each chromosome.

Genetic diseases are determined by the combination of genes for a particular trait that are on the chromosomes received from the father and the mother.

Recessive genetic disorders occur when an individual inherits the same abnormal gene for the same trait from each parent. If an individual receives one normal gene and one gene for the disease, the person will be a carrier for the disease, but usually will not show symptoms. The risk for two carrier parents to both pass the defective gene and, therefore, have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier like the parents is 50% with each pregnancy. The chance for a child to receive normal genes from both parents and be genetically normal for that particular trait is 25%. The risk is the same for males and females.

All individuals carry a few abnormal genes. Parents who are close relatives (consanguineous) have a higher chance than unrelated parents to both carry the same abnormal gene, which increases the risk to have children with a recessive genetic disorder.

As noted above, VLCAD deficiency is a genetic disorder of fatty acid metabolism. Metabolic disorders result from abnormal structure and functioning of a specific protein or enzyme. Enzymes are proteins that speed up the chemical reactions of the body. Enzymes are complicated proteins that must be folded in very precise ways in order to do their job of speeding up specific chemical reactions so that metabolism may proceed.

Affected Populations

Very long-chain acyl-CoA dehydrogenase deficiency is a rare metabolic disorder that was originally described in 1992. The introduction of heel-stick tandem mass spectrometry for the early diagnosis of VLCAD in newborns has markedly increased the number of infants in which the disorder is detected.

Accumulated data from a number of newborn screening programs estimates the incidence of VLCAD at one per 40,000 live births.

Related Disorders

Symptoms of the following disorders may be similar to those of very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency. Comparisons may be useful for a differential diagnosis:

Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency is considered the most common of the fatty acid oxidation disorders. It is characterized by deficiency of an enzyme that acts on medium-chain length fatty acids. During infancy or early childhood, affected individuals typically begin to experience acute, recurrent episodes provoked by prolonged fasting. Episodes may be characterized by elevated acid levels in blood and body tissues (metabolic acidosis), hypoketotic hypoglycemia, vomiting, lethargy, coma, and/or cardiorespiratory arrest. Additional findings may include fatty infiltration of the liver, secondary carnitine deficiency, elevated levels of certain organic acids in the urine, and other abnormalities. MCAD deficiency is inherited as an autosomal recessive trait. (For more information on this disorder, choose “medium chain” or “MCAD” as your search term in the Rare Disease Database.)
Glutaricaciduria II (GA II) is a metabolic disorder characterized by deficiency of either of two enzymes (i.e., electron transfer flavoprotein or electron transfer flavoprotein dehydrogenase). Symptoms and findings may be variable, with decreased disease severity appearing to correlate with increased age at symptom onset. In the neonatal period, associated abnormalities may include metabolic acidosis, hypoglycemia, elevated levels of multiple organic acids in the urine, an unusual odor of “sweaty feet,” poor muscle tone (hypotonia), enlargement of the liver (hepatomegaly), cardiomyopathy, and coma. In some of these cases, affected infants may also have facial abnormalities and multiple cysts in the kidneys. Later-onset disease may be associated with fasting-induced episodes characterized by hypoketotic hypoglycemia, metabolic acidosis, lethargy, coma, secondary carnitine deficiency, and/or other associated abnormalities. Glutaricaciduria II is inherited as an autosomal recessive trait. (For more information on this disorder, choose "glutaricaciduria II" as your search term in the Rare Disease Database.)

There are additional long chain fatty acid oxidation disorders and other inborn errors of metabolism that may be characterized by certain symptoms and findings similar to those potentially associated with VLCAD deficiency. (For more information on these disorders, choose the exact disease name in question as your search term in the Rare Disease Database.)

Reye syndrome is a rare disorder that predominantly affects children from approximately age four to 12 years. In some cases, Reye syndrome has initially been suspected in infants or children with fatty acid oxidation disorders, including VLCAD deficiency. Reye syndrome is primarily characterized by rapid accumulation of fat in the liver and sudden inflammation and swelling of the brain (acute encephalopathy). Associated symptoms and findings may include the sudden onset of severe, persistent vomiting; elevated levels of certain liver enzymes in the blood (hepatic transaminases); severe disorientation; episodes of uncontrolled electrical disturbances in the brain (seizures); and coma. The condition’s cause is unknown. However, there appears to be an association between the onset of Reye syndrome and the use of aspirin-containing medications (salicylates) in children or adolescents with certain viral illnesses, particularly upper respiratory tract infections (e.g., influenza B) or, in some cases, chickenpox (varicella). Due to the potential association between the use of aspirin-containing agents and the development of Reye syndrome, it is advised that such medications be avoided for infants, children, adolescents, and young adults affected by viral infections such as influenza or chickenpox. (For further information, use "Reye" as your search term in the Rare Disease Database.)

Standard Therapies

Diagnosis
VLCAD deficiency may be diagnosed based upon a thorough clinical evaluation; identification of characteristic findings (e.g., hypoketotic hypoglycemia, severe skeletal muscle weakness, heart enlargement); and the results of various specialized tests, including analysis conducted on various specimens, such as urine, blood, muscle, liver tissue, skin cells (cultured fibroblasts), and/or white blood cells (leukocytes). A thorough and complete family history is especially important in order to determine if there is an episode of sudden infant death (SID) in the family’s past. One estimate has it that prior to the advent of newborn screening VLCAD deficiency was responsible for up to 5% of all SIDS deaths.

In individuals with the disorder, urine organic acid analysis typically reveals reduced or absent ketone bodies and elevated levels of certain dicarboxylic acids (i.e., dicarboxylic aciduria, e.g., increased C6-C10, C12-C14 dicarboxylic acids). In some cases, there may be increased blood levels of the enzyme creatine phosphokinase (CPK) and the abnormal presence of myoglobin in the urine (myoglobinuria).
Removal (biopsy) and microscopic evaluation of small samples of liver tissue may also reveal fatty infiltration and structural changes of mitochondria, though this is not necessary for clinical diagnosis. In addition, abnormal enlargement of the heart (cardiomegaly) associated with cardiomyopathy may be apparent upon chest x-ray examination.

Prenatal diagnosis is available by enzyme measurement of either cultured cells or cells obtained from the amniotic fluid or during chorionic villus sampling (CVS). (With amniocentesis, a sample of fluid that surrounds the developing fetus is removed and analyzed, while CVS involves the removal of tissue samples from a portion of the placenta.)

Treatment
Disease management and treatment are primarily directed toward preventing and controlling acute episodes. Preventive measures include avoiding fasting for more than 10 to 12 hours and maintaining a low-fat, high-carbohydrate diet, with frequent feeding (i.e., to keep periods of fasting to a minimum). Additional recommendations may include the use of low-fat nutritional supplements, medium-chain triglycerides (e.g., MCT oil), and corn starch (e.g., at bedtime). Physicians may also advise supplementation with carnitine (Carnitor) and/or riboflavin.

If hospitalized for an acute episode, treatment may require the prompt administration of intravenous glucose (10% dextrose) and additional supportive measures as necessary.
Genetic counseling will also be of benefit for affected individuals and their families. In addition, as noted above, diagnostic testing of siblings is crucial to help detect and appropriately manage the condition. Other treatment for this disorder is symptomatic and supportive.

Investigational Therapies

A clinical trial is currently being conducted on treatment of VLCAD deficiency with triheptanoin, an artificial fat that is substituted for MCT oil in the diet. Published studies to date indicate improved glucose control and reduced episodes of rhabdomyolis in patients treated with triheptanoin. Cardiomyopathy may also be improved.

Bezafibrate is an experimental medication originally developed to lower blood cholesterol. It has coincidentally been shown to increase the amount of VLCAD protein in cells. Limited clinical studies have been published to study the use of bezafibrate in VLCAD deficiency but not active clinical trials are in progress.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: prpl@cc.nih.gov

For information about clinical trials sponsored by private sources, contact:
www.centerwatch.com

For information about clinical trials conducted in Europe, contact:
https://www.clinicaltrialsregister.eu/

Organizations related to Very Long Chain Acyl CoA Dehydrogenase Deficiency (LCAD)

References

TEXTBOOKS
Vockley J, Organic Acidemias and Disorders of Fatty Acid Oxidation. In: Emory and Rimoin Eds. Principles and Practice of Medical Genetics 5th edition. Harcourt Health Sciences Companies. 2006.
Eaton S. Very Long-Chain Acyl-CoA Dehydrogenase Deficiency. In: NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:439-40.

Behrman RE, et al., eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: W.B. Saunders Company; 2000:377-80.
Roe CR, Ding J. Mitochondrial Fatty Acid Oxidation Disorders. In: Scriver CR, Beaudet AL, Sly WS, et al. Eds. The Metabolic Molecular Basis of Inherited Disease. 8th ed. McGraw-Hill Companies. New York, NY; 2001:2297-326.

Vockley J, Rinaldo P, Bennett MJ, et al. Synergistic heterozygosity: disease resulting from multiple partial defects in one or more metabolic pathways. Mol Genet Metab. 2000;71:10-18.

JOURNAL ARTICLES
Schiff M, Mohsen AW, Karunanidhi A, McCracken E, Yeasted R, Vockley J. Molecular and cellular pathology of very-long-chain acyl-CoA dehydrogenase deficiency. Mol Genet Metab. 2013;109(1):21-7.
Shigematsu Y, Hirano S, Hata I, et al. Selective screening for fatty acid oxidation disorders by tandem mass spectrometry: difficulties in practical discrimination. J Chromatograph B Analyt Technol Biomed Life Sci. 2003;792:63-72.

Kluge S, Kuhnelt P, Block A, et al. A young woman with persistent hypoglycemia, rhabdomyolysis, and coma: recognizing fatty acid oxidation defects in adults. Crit Care Med. 2003;31:1273-76.
Spiekerkoetter U, Tenenbaum T, Heusch A, et al. Cardiomyopathy and Pericardial Effusion Point to a Fatty Acid b-Oxidation Defect after exclusion of an Underlying Infection. Pediatr Cardiol. 2003;24:295-97.

Solis JO, Singh RH. Management of fatty acid oxidation disorders: a survey of current treatment strategies. J Am Diet Assoc. 2002;102:1800-03.

Wilcox RL, Nelson CC, Stenzel P, et al. Postmortem screening for fatty acid oxidation disorders by analysis of Guthrie cards by tandem mass spectrometry in sudden unexpected death in infancy. J Pediatr. 2002;141:833-36.

Boles RG. Very long-chain acyl CoA dehydrogenase deficiency in an infant presenting with massive hepatomegaly. J Inherit Metab Dis. 2002;25:315-16.
Gregersen N, Andresen BS, Corydon MJ, et al. Mutation analysis in mitochondrial fatty acid oxidation defects: Exemplified by acyl-CoA dehydrogenase deficiencies, with special focus on genotype-phenotype relationship. Hum Mutat. 2001;18:169-89.

Marsden D, Nyhan WL, Barshop BA. Creatine kinase and uric acid: early warning for metabolic imbalance resulting from disorders of fatty acid oxidation. Eur J Pediatr. 2001;160:599-602.

Wood JC, Magera MJ, Rinaldo P, et al. Diagnosis of very long-chain acyl-CoA dehydrogenase deficiency from an infant’s newborn screening card. Pediatrics. 2001;108:E19.

Touma EH, Rashed MS, Vianey-Saban C, et al. A severe genotype with favorable outcome in very long-chain acyl-CoA dehydrogenase deficiency . Arch Dis Child. 2001;84:58-60.
Zytkovicz TH, Fitzgerald EF, Marsden D, et al. Tandem mass spectroscopic analysis for amino, organic and fatty acid disorders in newborn dried blood spots: a two-year summary from the New England Newborn Screening Program. Clin Chem. 2001;47:1945-55.
Gregersen N. Andresen BS, Bross P. Prevalent mutations in fatty acid oxidation disorders: diagnostic considerations. Eur J Pediatr. 2000;159 Suppl 3:S213-18.

Gregersen N, Bross P, Jorgensen MM, et al. Defective folding and rapid degradation of mutant proteins is a common disease mechanism in genetic disorders. J Inherit Metab Dis. 2000;23:441-47.

Roe CR, Wiltse HE, Sweetman L, et al. Death caused by perioperative fasting and sedation in a child with unrecognized very long-chain acyl-CoA dehydrogenase deficiency. J Pediatr. 2000;136:397-99.

Scholte HR, Van Coster RN, de Jonge PC, et al. Myopathy in very long-chain acyl-CoA dehydrogenase deficiency: clinical and biochemical differences with fatal cardiac phenotype. Neuromuscul Disord. 1999;9:313-19.
INTERNET

Baby’s First Test: Very-long-chain acyl-CoA dehydrogenase deficiency. Available at: http://www.babysfirsttest.org/newborn-screening/conditions/very-long-chain-acyl-coa-dehydrogenase-deficiency Accessed June 10, 2013.

Vianey-Saban C. Acyl-CoA dehydrogenase, very long chain, deficiency of. Orphanet. Last update: March 2004. Available at: http://www.orpha.net/consor/cgi-bin/OC_Exp.php?Lng=EN&Expert=26793 Accessed: June 10, 2013.

McKusick VA, ed. Online Mendelian Inheritance in Man (OMIM). The Johns Hopkins University. Entry Number: 201475; Last Update: 04/27/2011. Available at: http://www.omim.org/entry/201475?search=201475&highlight=201475 Accessed June 10, 2013.

Report last updated: 2013/06/27 00:00:00 GMT+0