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Phenylketonuria

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Synonyms of Phenylketonuria

Disorder Subdivisions

General Discussion

Phenylketonuria (PKU) is an inborn error of metabolism that is detectable during the first days of life with appropriate blood testing (e.g., during routine neonatal screening). PKU is characterized by absence or deficiency of an enzyme (phenylalanine hydroxylase) that is responsible for processing the essential amino acid phenylalanine. (Amino acids, the chemical building blocks of proteins, are essential for proper growth and development.) With normal enzymatic activity, phenylalanine is converted to another amino acid (tyrosine), which is then utilized by the body. However, when the phenylalanine hydroxylase enzyme is absent or deficient, phenylalanine abnormally accumulates in the blood and is toxic to brain tissue.

Symptoms associated with PKU are typically absent in newborns. Affected infants may be abnormally drowsy and listless (lethargic) and have difficulties feeding. In addition, untreated infants with PKU tend to have unusually light eyes, skin, and hair (light pigmentation) and may develop a rash that appears similar to eczema, an inflammatory skin condition that may be characterized by itching, redness, and blistering in affected areas.

Without treatment, most infants with PKU develop mental retardation that is typically severe. Those with untreated PKU may also develop additional neurologic symptoms, such as episodes of uncontrolled electrical activity in the brain (seizures), abnormally increased activity (hyperactivity), poor coordination and a clumsy manner of walking (gait), abnormal posturing, aggressive behavior, or psychiatric disturbances. Additional symptoms and findings may include nausea, vomiting, and a musty or "mousy" body odor due to the presence of a by-product of phenylalanine (phenylacetic acid) in the urine and sweat.

To prevent mental retardation, treatment consists of a carefully controlled, phenylalanine-restricted diet beginning during the first days or weeks of life. Most experts suggest that a phenylalanine-restricted diet should be life-long in persons with classical PKU. Classical PKU refers to persons with 2 severe mutations of the phenylalanine hydroxylase gene.

Symptoms

Infants with Phenylketonuria (PKU) typically appear normal at birth. With early screening and diet treatment, affected individuals may never show symptoms of PKU. However, untreated newborns (neonates) with this disorder who are not diagnosed in the first days of life may be weak and feed poorly. Other symptoms of PKU may include vomiting, irritability, and/or a red skin rash with small pimples (eczematoid). These infants with this disorder generally have a musty or "mousy" body odor caused by phenylacetic acid in the urine and/or perspiration.

If children with phenylketonuria (PKU) are not treated, developmental retardation may be obvious at several months of age. The average IQ of untreated children is usually less than 50. High levels of phenylalanine interfere with a chemical in the body that is responsible for maintaining pigmentation (melanin). Therefore, affected children usually have a fair complexion and light hair. Symptoms of autism are not uncommon in untreated persons.

Neurological symptoms are present in only some patients with phenylketonuria (PKU) and may vary greatly. Seizures occur in about 25 percent of older children and abnormalities appear on brain wave tests (EEG) in 80 percent of patients. Jerky muscle movements (spasticity), abnormally tight muscles (hypertonicity), and/or increased deep tendon reflexes are among the most frequent neurological symptoms. About 5 percent of children with symptoms of PKU become physically disabled. Slow writhing movements, involuntary muscle movements, and tremors occur in some cases.

Untreated females with this disorder often have spontaneous abortions or fetal growth delays (intrauterine growth retardation). Children of women with phenylketonuria (PKU) may have an abnormally small head (microcephaly) and/or congenital heart disease, and a variety of facial abnormalities. There is a strong relationship between the severity of these symptoms and high levels of phenylalanine in the mother. As a result, all women with PKU who have stopped treatment should return to the diet before conception and continue on the diet throughout any pregnancy.

Causes

Phenylketonuria is inherited as an autosomal recessive trait. Genetic diseases are determined by two genes, one received from the father and one from 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 defective gene that causes PKU is located on the long arm (q) of chromosome 12 (12q24). However, not all children with PKU have the same genetic mutation. More than 300 different changes (mutations) in the PKU gene have been identified. Because the different mutations result in varying degrees of elevation in blood phenylalanine, the diet of each child must be adjusted to the individual tolerance for the amino acid. Laboratory tests in infants with PKU typically confirm plasma levels of phenylalanine that are ten to 60 times above normal levels.

The symptoms of PKU develop because of a defective liver enzyme, phenylalanine hydroxylase. This enzyme enables phenylalanine to be metabolized into tyrosine. Mental retardation in PKU is a direct result of elevated levels of phenylalanine in the brain which causes the destruction of the fatty covering (myelin) of individual nerve fiber in the brain. It can also cause depression by reducing the levels of dopamine and serotonin in the brain.

Affected Populations

Phenylketonuria is a rare disorder that affects males and females in equal numbers. The reported incidence of PKU from newborn screening programs ranges from one in 13,500 to 19,000 newborns in the United States. The incidence varies in other parts of the world. PKU affects people from most ethnic backgrounds, although it is rare in Americans of African descent and Jews of Ashkenazi ancestry.

Related Disorders

Symptoms of the following disorders can be similar to those of phenylketonuria. Comparisons may be useful for a differential diagnosis:

Tetrahydrobiopterin (BH4) deficiency is a rare genetic neurological disorder of infancy. It is caused by an inherited inborn error of metabolism. Tetrahydrobiopterin is a natural substance (coenzyme) that enhances the action of other enzymes. When Tetrahydrobiopterin is deficient, an abnormally high blood level of the amino acid phenylalanine, along with low levels of certain neurotransmitters, usually occurs. To avoid irreversible neurological damage, diagnosis and treatment of this progressive disorder is essential as early as possible in life. Symptoms of this disorder usually include neurological abnormalities, lack of muscle tone, loss of coordination, seizures, and/or delayed motor development. (For more information on this disorder, choose "Tetrahydrobiopterin" as your search term in the Rare Disease Database.)

Hyperphenylalaninemia is identified by the presence of abnormally high blood levels of the amino acid phenylalanine in newborns. It may or may not be associated with elevated levels of another amino acid, tyrosine, in these children. This disorder may be a symptom of phenylketonuria (PKU) or it can be linked with short-term deficiencies of either phenylalanine hydroxylase or p-hydroxyphenylpyruvic acid oxidase.

There are many other disorders of infancy with symptoms that are similar to those of PKU. However, the screening test that is done for this disorder in almost every hospital allows physicians to diagnose this disorder and distinguish it from other neuromuscular or metabolic disorders.

Standard Therapies

Diagnosis
Prenatal diagnosis of phenylketonuria (PKU) is available, and routine neonatal screening is required by law in the United States and in most hospitals in developed countries. The test requires a drop of blood taken from the baby's heel. It is also possible to detect if a child is carrying a single defective gene that causes PKU (heterozygotes).

Treatment
The goal of treatment for PKU is to keep plasma phenylalanine levels within 2-6 mg percent near the normal range of 1 mg percent. This is generally achieved through carefully planned and monitored diet. Limiting the child's intake of phenylalanine must be done cautiously because it is an essential amino acid. A carefully maintained diet can prevent mental retardation as well as neurological, behavioral, and dermatological problems. Treatment must be started at a very young age (under 3 months), or some degree of mental retardation may be expected. However, even some late-treated children have done quite well. Studies have repeatedly demonstrated that children with PKU who are treated with a low phenylalanine diet before the age of three months do well, with an IQ in the normal range.

If people with PKU stop controlling their dietary intake of phenylalanine, neurological changes usually occur. IQs may decline. Other problems that may appear and become severe once dietary regulation is stopped include difficulties in school, behavioral problems, mood changes, poor visual-motor coordination, poor memory, poor problem-solving skills, fatigue, tremors, poor concentration, and others such as depression.

After years of controversy, there now is nearly universal acceptance among clinicians treating PKU that the diet needs to be continued indefinitely. Also, many clinicians believe that adults with PKU who stopped the diet in childhood or beyond need to return to the diet. Many young adults have restarted the diet and found that the majority of their problems have been improved or have disappeared as a result of lowered blood phenylalanine levels.

A Consensus Panel convened by the National Institutes of Health (NIH) in October 2000 concluded that it is important for people affected by PKU to adhere to the special diet beyond childhood. In a statement issued at the conclusion of its three-day meeting, the panel noted that dietary control of PKU is one component of a lifelong treatment program that should include regular blood tests, and regular visits to a PKU clinic.

Because phenylalanine occurs in practically all natural proteins, it is impossible to adequately restrict the diet using natural foods alone without compromising health. For this reason, special phenylalanine-free food preparations are extremely important. There are a number of phenylalanine-free formulas available in the US and in other countries. Foods high in protein, such as meat, milk, fish and cheese are typically not allowed on the diet. Naturally low protein foods such as fruits, vegetables, and some cereals are allowed in limited quantities.

If the intake of phenylalanine is too severely limited in people with PKU, vitamin B-12 deficiency and symptoms of phenylalanine deficiency may develop. These may include fatigue, aggressive behavior, severe loss of appetite (anorexia), and sometimes low iron levels in the blood (anemia). Plasma levels of phenylalanine must be monitored regularly.

In very rare instances, abnormally high levels of phenylalanine may also be caused by a deficiency of tetrahydrobiopterin because of insufficient amounts of either biopterin, an enzyme cofactor, or the enzyme dihydropteridine reductase. Tetrahydrobiopterin is involved in the production of chemicals in the brain (neurotransmitters) such as serotonin, dopamine, and norepinephrine. Low levels of these neurotransmitters could account for the progressive neurological deterioration of children with Tetrahydrobiopterin deficiency, in spite of controlled plasma phenylalanine. (For more information on Tetrahydrobiopterin deficiency, see the Related Disorders section of this report.)

On 13th of December in 2007, Kuvan (sapropterin hydrochloride) was approved by the U.S. Food and Drug Administration to treat inherited phenylketonuria, or PKU. Kuvan is the first and only FDA-approved medication for PKU to reduce blood Phe levels in patients with hyperphenylalaninemia (HPA) due to tetrahydrobiopterin (BH4-) responsive PKU. Kuvan is a pharmaceutical formulation of BH4, the natural cofactor for the PAH enzyme, which stimulates activity of the residual PAH enzyme to metabolize Phe into tyrosine. Kuvan is to be used in conjunction with a Phe-restricted diet. For more information please the contact the following.

BioMarin Pharmaceutical Inc.
Susan Berg
Corporate Communications
sberg@bmrn.com
Tel. (415) 506-6594
or

BioMarin Pharmaceutical Inc.
105 Digital Drive
Novato, CA 94949
Tel: 415.506.6700
Fax: 415.382.7889

BioMarin has initiated an expanded access program for Kuvan in the U.S. Anyone interested in learning more about this program should speak with their physician or call (877) 811-7327.

Investigational Therapies

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 website.

For information about clinical trials being conducted at the National Institutes of Health (NIH) Clinical Center in Bethesda, MD, contact the NIH 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

Scientists are involved in the research and development of improved medical foods for adults with PKU.

Tetrahydro-L-biopterin dihydrochloride (designated RS 5678) is being studied for the treatment of tetrahydrobiopterin deficiency phenylalaninemia. For more information, affected individuals may have their physicians contact:

B. Schirks, M.D.
Schachenstrasse 4
CH 8907 Wettswila A.
Switzerland
Tel. 01 700 1645.

Phenylketonuria Resources

NORD Member Organizations:

(To become a member of NORD, an organization must meet established criteria and be approved by the NORD Board of Directors. If you're interested in becoming a member, please contact Susan Olivo, Membership Manager, at solivo@rarediseases.org.)

Other Organizations:

References

TEXTBOOKS
Cabello JF, Levy HL. Phenylketonuria. In: NORD Guide to Rare Disorders. Lippincott Williams & Wilkins. Philadelphia, PA. 2003:488.

Bennett JC, Plum F., eds. Cecil Textbook of Medicine. 20th ed. Philadelphia, PA: W.B. Saunders Co; 1996:1105-8.

Fauci AS, et al., eds. Harrison's Principles of Internal Medicine, 14th Ed. New York, NY: McGraw-Hill, Inc; 1998:2198-9.

Beers MH, Berkow R., eds. The Merck Manual, 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999:2390, 2396-7.

Scriver CR, et al., eds. The Metabolic and Molecular Basis of Inherited Disease. 8th Ed. New York, NY; McGraw-Hill Companies, Inc; 2001:Chapter on Phenyketonuria.

Adams, RD, et al., eds. Principles of Neurology. 6th ed. New York, NY: McGraw-Hill, Companies; 1997:952-3.

Lyon G, et al., eds. Neurology of Hereditary Metabolic Diseases in Childhood. 2nd ed. New York, NY: McGraw-Hill Companies; 1996:87-9.

REVIEW ARTICLES
De la Cruz F, Koch R. Genetic Implications for newborn screening for phenylketonuria. Clin Perinatol. 2001;28:419-24.

van Spronsen FJ, Smit PG, Koch R. Phenylketonuria: tyrosine beyond the phenylalanine diet. J Inherit Metab Dis. 2001;24:1-4.

Griffith P. Neuropsychological approaches to treatment policy issues in phenylketonuria. Eur J Pediatr. 2000;159:Suppl 2:S82-86, comment Eur J Pediatr. 2000;159:Suppl 2:S87-88.

Van Spronsen FJ, van Rijn M, Bekhof J, et al. Phenylketonuria: tyrosine supplementation in phenylalanine restricted diets. Am J Clin Nutr. 2001;73:153-57.

JOURNAL ARTICLES
Muntau AC, Röschinger W, Habich M, et al. Tetrahydrobiopterin as an alternative treatment for mild phenylketonuria. N Engl J Med. 2002;347:2122-32.

Seashore MR. Tetrahydrobiopterin and dietary restriction in mild phenylketonuria. N Engl J Med. 2002;347:2094-95.

American Academy of Pediatrics, Committee on Genetics. American Academy of Pediatrics:Maternal phenylketonuria. Pediatrics. 2001;107:427-28.

National Institute of Health Consensus Development Conference Statement: phenylketonuria: screening and management, October 16-18, 2000. Pediatrics. 2001;108:972-82.

Rohr FJ, Munier AW, Levy HL. Acceptability of a new modular protein substitute for the dietary treatment of phenylketonuria. J Inherit Metab Dis. 2001;24:623-30.

Erlandsen H, Stevens RC. A structural hypothesis for BH4 responsiveness in patients with mild forms of hyperphenylalaninemia and phenyketonuria. J Inhab Metab Dis. 2001;24:213-30.

Kalsner LR, Rohr FJ, Strauss KA, et al. Tyrosine supplementation in phenylketonuria: diurnal blood tyrosine levels and presumptive brain influx of tyrosine and other large neutral amino acids. J Pediatr;2001;139:421-27.

FROM THE INTERNET
McKusick VA, Ed. Online Mendelian Inheritance in Man (OMIM). The Johns Hopkins University. Entry Number; 261600: Last Edit Date; 1/8/2003.

Report last updated: 2007/05/01 00:00:00 GMT+0