A 3-year-old girl is brought to the emergency department by her parents for vomiting and lethargy for the past day and a new seizure one hour ago that lasted approximately 3 minutes. They report that she is taking amoxicillin for otitis media that was diagnosed two days ago. On physical examination, she is noted to have a fruity odor and has dry mucous membranes. A urine sample is obtained and is noted to have a distinct sweet-smelling odor. Laboratory results confirm a diagnosis of maple syrup urine disease (MSUD).
Which of the following amino acids is least likely to be elevated in this patient?
- A) Cysteine
- B) Isoleucine
- C) Leucine
- D) Valine
A) Cysteine
Maple syrup urine disease (MSUD), also known as brached-chain ketoaciduria, is characterized by the accumulation of branched-chain amino acids. Cysteine is the only amino acid listed that does not fit this category. MSUD is caused by a deficiency of branched-chain alpha-ketoacid dehydrogenase complex (BCKDC), the second enzyme of the metabolic pathway of the three branched-chain amino acids: leucine, isoleucine, and valine. MSUD is characterized by psychomotor delay, feeding problems, and a maple syrup odor of the urine. Onset is variable depending upon which of the five clinical phenotypes is present.
Key Learning Point
Maple syrup urine disease results from the accumulation of the three branched-chain amino acids which are leucine, isoleucine, and valine.