Binkert, F.

Blau, N.

Guardamagna, O.

Kierat, L.

Matasovic, A.

Ponzone, A.

Ponzone, R.

Spada, M.

Viora, E.

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Guardamagna et al.: Prenatal diagnosis of DHPR deficiency 19 Pteridines Vol. 3, pp. 1 9 - 2 1 Short Communication Prenatal Diagnosis of Dihydropteridine Reductase Deficiency in a Twin Pregnancy O. Guardamagna, M. Spada, A. Ponzone, E. Viora*, R. Ponzone*, F. Binkert**, A. Matasovic***, L. Kierat*** and N. Blau*** Department of Pediatrics and * Department of Obstetrics and Gynecology, Piazza Polonia, 94, 10126 Torino Italy ** Institute of Medical Genetics and *** Department of Pediatrics, University of Zürich, Switzerland (Received March 1992) Introduction Three inborn errors of metabolism are known to cause deficiency of tetrahydrobiopterin (BH4), the natural cofactor of aromatic amino acid hydroxylases (1). Guanosine triphosphate cyclohydrolase I deficiency (Mc Kusick 23391) and 6-pyruvoyl tetrahydropterin synthase deficiency (Mc Kusick 26164) lead to im-paired BH4 biosynthesis, dihydropteridine reductase deficiency (DHPR; Mc Kusick 26263) prevents BH4 from being regenerated after oxidation in the coupled reaction with hydroxylases. All these traits are inher-ited recessively. Patients develop, in addition to hy-perphenylalaninemia, severe neurological symptoms due to biogenic amine deficiency, and they are not responsive to a phenylalanine restricted diet. Since the prognosis may be poor even if patients were treated early with diet and substitutive therapy, prenatal di-agnosis was recently made possible following different procedures (2). Problems inherent in prenatal diagnosis of a twin pregnancy at risk for D H P R deficiency are presented. Case Report and Methods Two second cousin parents, originally from Italy, known to be heterozygotes for D H P R deficiency since they had an affected girl (3) and an heterozygous boy, requested a prenatal diagnosis in the course of a third pregnancy. Pteridines / Vol. 3 / No. 1 /2 Copyright © 1992 Walter de Gruyter • Berlin • New York An ultrasound scan was performed at 15 weeks and a twin gestation was visualized: a single posterior placenta with two amniotic sacs separated by a thin membrane were typical of a monozygotic pregnancy, and consistent with the male sex of both fetuses. In order to avoid the increased risk of repeated needle insertions, amniocentesis was performed after select-ing a site in the maternal abdomen suitable to sample both the sacs without crossing the placenta. Under real-time ultrasound control, a 20-Gauge spinal needle was inserted transabdominally into the first amniotic sac (fetus A), 20 ml of amniotic fluid (AF) were removed, and 2 ml of indigo carmine were in-jected. The stylet was inserted and the amniotic mem-brane was crossed. A few drops of colorless A F con-firmed that the second sac (fetus B) had been entered, but not a sufficient sample for pterin analysis and amniocyte culturing could be aspirated, probably be-cause the fetus was moving. As the mother had al-ready had a vaginal hemorrage, and the ultrasound picture was predictive for monozygotic gestation, a second insertion of the needle was not performed. However, the parents being informed of a residual 17% risk of a dizygotic pregnancy (4) chose to avoid any risk of fetus Β being affected. Cordocentesis was performed at 19 weeks gestation under ultrasound real-time visualization by the same technique employed for amniocentesis. Samples of fetal blood were obtained by transabdominal punc-20 Guardamagna et al.: Prenatal diagnosis of DHPR deficiency Table 1. Pterins, neurotransmitter metabolites and amino acids in amniotic fluid, and DHPR activity in amniocytes and in fetal erythrocytes. Fetus at risk Weeks of gestation amniotic fluid amniotic fluid DHPR activity Ν (nmol/1) Β 5-HIAA HVA Phe (μπιοΐ/ΐ) Tyr amnio-cytes* erythro-cytes** Fetus A 15 37 23 125 168 61 57 13.4 19 51 19 146 188 50 46 1.8 Fetus Β 19 49 18 142 174 54 50 1.4 Normal values 15 29 12 92 50 22 2 <120 <109 23 62 29 135 144 49 5 * nmol NADH/min mg prot ** mU/mg Hb Ν = neopterin; Β = biopterin; 5-HIAA = 5-hydroxyindoleacetic acid; HVA = homovanillic acid ture of the umbilical vein at the site of placental insertion for each fetus by two different needle inser-tions, and the purity of fetal blood was immediately controlled by Coulter Counter Channelyzer. Contex-tually, AF samples were taken from both sacs. Pterins in AF were measured, after oxidation with manganese dioxide and subsequent deproteinization with trichloroacetic acid, by HPLC (5). 5-Hydroxyin-dolacetic acid (5-HIAA) and homovanillic acid (HVA) in AF were measured by HPLC with an ESA Coul-ochem 5100 A electrochemical detector (2). Amino acids were measured using a Biotronic ion-exchange amino acid analyser. DHPR activity was measured in amniocyte extracts obtained after 21 days of culturing and in fetal erythrocytes, as described by (6). Spontaneous premature delivery of two phenotypi-cally normal males occurred at 34 weeks gestation. metabolite concentrations were normal in these cases as well as in the case of a fetus homozygous for DHPR deficiency (2). These findings might explain the ab-sence in such patients of neonatal symptoms of bio-genic amine deficiency, possibly because of dopamine and serotonin supply from the mother to the fetus throughout gestation. The few prenatal diagnoses of DHPR deficiency till now have been performed in the second trimester of pregnancy. Since DHPR activity is expressed in all fetal tissues (7), either early amniocentesis or cho-rionic villus sampling will allow the first-trimester diagnosis. However, in twin gestations every proce-dure will be complicated by the need of repeated obstetric manoeuvres to exclude dizygosity even in front of an ultrasound appearance of monozygotic pregnancy, so still allowing all possible options. Results and Discussion Biochemical analyses of AF were not informative for antenatal diagnosis, as the concentrations of amino acids, pterins and neurotransmitter metabolites were in the normal range (Table 1). The reduced DHPR activity detected in cultured amniocytes from fetus A, as well as in fetal erythrocytes from both fetuses, was consistent with their heterozygosity, as demonstrated after birth by the assay of enzyme activity in periph-eral erythrocytes. These findings confirm that in pregnancies at risk for DHPR deficiency the measurement of AF neopterin and biopterin allows the detection of only the affected fetus, whereas the enzyme assay on amniocytes or fetal erythrocytes is necessary to distinguish the het-erozygous from the normal fetus. Neurotransmitter Acknowledgement This work was supported in part by the Swiss Na-tional Science Foundation (to Ν. B.), project No. 31-28797.90. References 1. Blau, Ν. (1988) Inborn errors of pterin metabolism. Annu. Rev. Nutr. 8, 185 — 209. 2. Blau, Ν., Niederwieser, Α., Curtius, H. Ch., Kierat, L., Leimbacher, W., Matasovic, Α., Binkert, F., Lehmann, H., Leupold, D., Guardamagna, O., Ponzone, Α., Schmidt, H., Coskun, T., Ozalp, I., Giugliani, R., Biasucci, G. & Giovan-nini, M. (1989) Prenatal diagnosis of atypical phenylketon-uria. J. Inher. Metab. Dis. 12, Suppl. 2, 295-299 . 3. Ponzone, Α., Guardamagna, O., Ferraris, S., Bracco, G. & Niederwieser, A. (1988) Two mutations of dihydropteridine reductase deficiency. Arch. Dis. Child. 63, 154—157. Pteridines / Vol. 3 / No. 1/2 Guardamagna et al:. Prenatal diagnosis of D I I P R deficiency 21 4. Townsend, R. R., Simpson, G. F. & Filly, R. A. (1988) Membrane thickncss in ultrasound prediction of chorionicity of twin gestations. J. Ultrasound Med. 7, 327 — 331. 5. Niederwieser, Α., Shintaku, H., Hasler, Th., Curtius, H. Ch., Lehmann, H., Guardamagna , O. & Schmidt, H. (1986) Pre-natal diagnosis of "dihydrobiopterin synthetase" deficiency, a variant form of phenylketonuria. Eur. J. Pediatr. 145, 7 1 5 - 7 2 1 . 6. Arai, Ν., Narisawa, Κ., Hayakawa, Η. & Tada, Κ. (1982) Hyperphenylalaninemia due to dihydropteridine reductase deficiency: Diagnosis by enzyme assay on dried blood spots. Pediatrics 70, 4 2 6 - 4 3 0 . 7. Bracco, G., Iavarone, Α., Pagliardini, S., Levis, F., Guar -damagna, O., Ferraris, S. & Ponzone, A. (1987) in: Uncon-jugated Pterins and Related Biogenic Amines (Curtius, H. Ch., Blau, Ν. & Levine, R. Α., eds.) pp. 2 6 5 - 2 7 3 , Walter de Gruyter, Berlin, New York. Pteridines / Vol. 3 / No. 1/2 

Prenatal Diagnosis of Dihydropteridine Reductase Deficiency in a Twin Pregnancy

Prenatal Diagnosis of Dihydropteridine Reductase Deficiency in a Twin Pregnancy

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