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01 April 2011

Drug-resistant epilepsia and fulminant valproate liver toxicity. Alpers-Huttenlocher syndrome in two children confirmed post mortem by identification of p.W748S mutation in POLG gene

Ewa PronickaADEFG, Anna Weglewska-JurkiewiczABCD, Maciej PronickiBC, Jolanta Sykut-CegielskaBD, Pawel KowalskiB, Magdalena PajdowskaBD, Irena JankowskaBD, Katarzyna KotulskaBD, Piotr KalicinskiB, Joanna Jakobkiewicz-BaneckaBCD, Grzegorz WegrzynADEF

DOI: 10.12659/MSM.881716

Med Sci Monit 2011; 17(4): CR203-209

Abstract

Background: POLG (polymerase gamma) gene mutations lead to a variety of neurological disorders, including Alpers-Huttenlocher syndrome (AHS). The diagnostic triad of AHS is: resistant epilepsy, liver impairment triggered by sodium valproate (VA), and mitochondrial DNA depletion.
Material/Methods: A cohort of 28 children with mitochondrial encephalopathy and liver failure was qualified for retrospective study of mitochondrial DNA depletion and POLG mutations.
Results: The p.W748S POLG gene mutation was revealed in 2 children, the only ones in the cohort who fulfilled the AHS criteria. Depletion of mtDNA (16% of control value) was confirmed post mortem in available liver tissue and was not detected in the muscle. The disease started with drug-resistant seizures, failure to thrive and developmental regression at the ages of 7 and 18 months, respectively. Irreversible liver failure developed after VA administration. Co-existence of epilepsy, VA liver toxicity, lactic acidemia and muscle respiratory chain dysfunction led finally to the diagnosis of mitochondrial disorder (and AHS suspicion).
Conclusions: Our results confirm, for the first time, the occurrence of a pathology caused by POLG gene mutation(s) in the Polish population. POLG mutation screening and mtDNA depletion assessment should be included in differential diagnosis of drug-resistant epilepsy associated with a hepatopathy.

Keywords: Liver - pathology, Fatal Outcome, Epilepsy - enzymology, Drug Resistance, Diffuse Cerebral Sclerosis of Schilder - pathology, DNA-Directed DNA Polymerase - genetics, Child, Amino Acid Substitution - genetics, Mutation - genetics, Postmortem Changes, Spectrophotometry, Valproic Acid - therapeutic use

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Medical Science Monitor eISSN: 1643-3750
Medical Science Monitor eISSN: 1643-3750