BIOCHEMICAL BASIS OF

PHENYLKETONURIA AND MAPLE SYRUP

SYNDROME
PHENYLKETONURIA
Phenylketonuria (PKU) is an autosomal recessive metabolic genetic disorder
characterized by homozygous or compound heterozygous mutations in the gene for
the hepatic enzyme phenylalanine hydroxylase (PAH). When this enzyme is
defective a block is produced in a biochemical pathway.
In humans, phenylalanine is normally oxidized by the enzyme phenylalanine
hydroxylase (PAH) to form the amino acid tyrosine. This is in fact the normal
biosynthetic route to tyrosine for humans. From tyrosine, there are further
connections to the biosynthesis of catecholamines, melanin, hormones, etc. Usually,
dietary intake of phenylalanine and tyrosine, and the body's demand for Phe and
Tyr, are fairly closely balanced. However, when there is too much phenylalanine in
the body, it must be eliminated, either by excretion or by biochemical reaction.
There are two routes by which the excess Phe can be metabolized: oxidation to
tyrosine (the normal and main route for degradation of Phe, and the normal route
for biosynthesis of Tyr), and transamination to phenylpyruvate and subsequent
further metabolism.

1.)Oxidation of Phenylalanine and Biosynthesis of Tyrosine

If there is sufficient phenylalanine in the diet, then humans usually have no difficulty
in synthesizing adequate amounts of tyrosine from the dietary phenylalanine. The
enzyme catalyzing the reaction is phenylalanine hydroxylase (PAH), a mixedfunction mono-oxygenase that uses molecular oxygen. This enzyme also uses the
cofactortetrahydrobiopterin (BH4), which is oxidized in the course of the reaction to
dihydrobiopterin (BH2). The cofactor must be regenerated by a separate system of
enzymes for PAH action to continue.
2.) Transamination of amino acids

Transaminases catalyze the transfer of -NH2 groups from the amino acids, onto
alpha-ketoglutarate. Many different transaminases are known, and they are
generally of broad specificity for amino acids (that is, one enzyme can accept as
substrates two or more different amino acids). All have the same cofactor
requirement - pyridoxal phosphate (vitamin B6).
Transamination of phenylalanine to phenylpyruvate is normally of negligible
importance, so long as the main route is functioning. However, if the main route is
blocked for some reason, then transamination of Phe becomes quite important. In
fact, the production of the distinctive minor metabolite, phenylpyruvate, can be
used to diagnose deficiencies in the main route of metabolism of phenylalanine.

ABOUT THE DISEASE (PKU)

If there is abnormal PAH activity, with little or no conversion of phenylalanine to

tyrosine, then the catabolism of phenylalanine is blocked and serum levels of
phenylalanine rise (hyperphenylalaninemia). Then the side reactions start to
produce metabolites of phenylalanine. These include phenylacetate, phenyllactate,
phenylpyruvate, and phenylethylamine. These metabolites are excreted through
the urine. The disease is called phenylketonuria because one of the dominant
metabolites contains a ketone group; this is phenylpyruvate, an alpha-keto acid.

CAUSES OF PHENYLKETONURIA
The most common cause for a lack of PAH activity is a genetic defect in the gene for
PAH. Most patients suffering from PKU have one or another of several possible
mutations in the gene for PAH.
A secondary cause of lack of PAH
activity is a defect in the generation of adequate amounts of the cofactor
tetrahydrobiopterin (BH4). Defects in biopterin metabolism account for 1% - 3% of
all cases of hyperphenylalaninemia. Defects in the regeneration of the cofactor
tetrahydobiopterin (BH4) account for a small fraction of PKU cases. Such cases are
sometimes identified as "malignant" PKU, because of the progressive deterioration
of the neurological function, where not only the phenylketonuria is a problem, but
ends in serious defects in neurotransmission.

MAPLE SYRUP SYNDROME

Maple syrup urine disease, also called branched-chain aminoaciduria, is an inherited
disorder in which the body is unable to process certain protein building blocks
(amino acids) properly. The condition gets its name from the distinctive sweet odor
of affected infants' urine and is also characterized by poor feeding, vomiting, lack of
energy (lethargy), and developmental delay.
Maple syrup urine disease (MSUD) is caused by a deficiency of the mitochondrial
branched-chain a-keto acid dehydrogenase (BCKAD) complex. The biochemical basis
of this disease is the inability to metabolize branched-chain a-keto acids (BCKAs)
derived from the essential branched-chained amino acids (BCAAs) leucine,
isoleucine, and valine. A deficiency in BCKAD leads to an accumulation of those
three amino acids and their corresponding branched-chain -keto acids. The
elevated BCAAs and BCKADs may have severe clinical consequences including
ketoacidosis, mental retardation, and neurological impairment.
The BCAAs represent approximately 35%40% of the essential amino acids in
skeletal muscle. Following the ingestion of protein the BCAAs represent about 60%
of the increase in amino acids in the blood. In skeletal muscle the BCAAs represent
a significant source of carbon atom as an alternate to lipid and carbohydrate as a
source of energy. The BCAAs are also actively metabolized for energy in the heart,
kidneys, brain and adipose tissue. In the liver, oxidation of the BCAAs provides

significant carbon for the production of the ketone bodies used by the brain during
periods of fasting.
The BCKAD complex is a multimeric enzyme composed of three catalytic subunits.
The E1 portion of the complex is a thiamine pyrophosphate (TPP)-dependent
decarboxylase with a subunit structure of 22. The E2 portion is a transacylase
composed of 24 lipoic acid-containing polypeptides. The E3 portion is a
homodimeric flavoprotein. The activity of BCKAD is regulated by two additional
subunits, a kinase and a phosphatase that reversibly
phosphorylate/dephosphorylate the complex.

Based upon the overall clinical presentation, the maple syrup urine disease (MSUD)
patients can be divided into five phenotypic classifications:
1.) CLASSIC
Classic MSUD is defined by neonatal onset of encephalopathy and is the most
severe form of the disorder. The levels of the BCAAs, especially leucine are
dramatically elevated in the blood, urine and cerebrospinal fluid of affected infants.
The level of BCKAD activity in classic MSUD patients is less than 2% of normal.
Affected infants appear normal at birth but symptoms develop rapidly appearing by
4 to 7 days after birth. The first distinctive signs are lethargy and little interest in
feeding. As the disease progresses infants will exhibit weight loss and progressive
neurological deterioration.
2.) INTERMEDIATE
Intermediate MSUD is distinguished from classic in that patients do not experience
the severity of classic MSUD in the neonatal period. Infants will have persistent
elevation in BCAAs in body fluids as well as neurological impairment. The level of
BCKAD in intermediate MSUD individuals ranges from 3% to 30% of normal.
3.) INTERMITTENT
In patients with the intermittent form of MSUD the activity of BCKAD ranges from
5% to 50% of normal. These individuals will show normal early development with
normal intelligence. During periods when patients are asymptomatic their fluid
levels of BCAAs will be normal.
4.) THIAMINE-RESPONSIVE
There is a similar course of progress in the symptoms of thiamine-responsive MSUD
patients to that seen in intermediate MSUD patients. Plasma BCAA levels are around
5 times normal and alloisoleucine is characteristically detectable in these patients.
Administration of thiamine and consumption of a low protein diet results in a
reduction of BCAA levels to normal.
5.) DEHYDROLIPOYL DEHYDROGENASE (E3) DEFICIENT

This form of MSUD is due to a deficiency in the E3 component of the BCKAD

complex. This form of MSUD is very rare with only 20 reported cases. The symptoms
of the E3-deficient form are similar to those of intermediate MSUD, but there is an
accompanying severe lactic acidosis (physiological condition characterized by low
pH in body tissues and blood (acidosis) accompanied by the buildup of lactate,
especially L-lactate, and is considered a distinct form of metabolic acidosis).

References:
https://www.uic.edu/classes/phar/phar332/Clinical_Cases/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC441427/pdf/jcinvest00491-0034.pdf
http://themedicalbiochemistrypage.org
http://ghr.nlm.nih.gov/condition/maple-syrup-urine-disease
http://emedicine.medscape.com/article/947781-overview

Laura Tomi
Course: Medical chemistry & biochemistry 2
Medical Studies in English
Medicinski fakultet Sveuilita u Zagrebu