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Chenodeoxycholic acid (CDCA) is an essential drug for patients with rare metabolic disease cerebrotendinous xanthomatosis (CTX). To ensure continuation of treatment, the Amsterdam UMC hospital pharmacy developed pharmacy compounded CDCA capsules when the authorized CDCA capsules were no longer available for Dutch patients. This study reports the safety of pharmacy compounded CDCA through pharmacovigilance monitoring and assesses its effectiveness by evaluating biochemical outcome measures, both in patients who were previously treated with authorized CDCA and subsequently switched to the compounded formulation and in new patients. Data were generated during routine patient care and collected retrospectively. Adverse events were reported by 45% of the patients; the most reported adverse events were diarrhea (16%), constipation (7%), and fatigue (7%). Biochemically, plasma cholestanol levels and urinary bile alcohol levels remained normalized before and after switching from the authorized product to pharmacy compounded capsules. It can be concluded that the pharmacy compounded CDCA capsules are well tolerated by patients with CTX and that the desired biochemical effect was maintained, supporting the use of a compounded formulation when the authorized product is unavailable.

Phenylketonuria (PKU) is an autosomal recessive disorder caused by a deficiency of phenylalanine hydroxylase (PAH), leading to the accumulation of phenylalanine (Phe) and an increased risk of developmental disorders. Treatment involves a Phe-restricted diet, amino acid supplements, and for a subset of patients, a tetrahydrobiopterin (BH4) chaperone. Managing PKU during pregnancy is challenging due to changing protein and energy needs, stricter Phe control, nausea, and unpalatable supplements. In rare cases of simultaneous maternal and fetal PKU, Phe tolerance may increase less throughout gestation, raising the demands on the patient and caregivers. There are few reports and no guidelines on the management of PKU during pregnancies in which both mother and fetus have PKU, hereafter referred to as maternal-fetal PKU (mfPKU). This report outlines our approach for successfully managing two consecutive mfPKU pregnancies. We emphasize a patient-centered approach, focusing on patient education and close collaboration with a multidisciplinary metabolic team. This involves regular monitoring of body weight, blood Phe levels, and calorie intake through an online food diary to tailor individual recommendations for natural protein restriction and amino acid supplements.

Mucopolysaccharidosis II is a rare, X-linked disease, with very few reports of affected female patients. Natural history data describe a predominantly male population, and appropriate disease characterization in female patients is lacking. This analysis explores the somatic disease burden and clinical progression of female patients with MPS II enrolled in the Hunter Outcome Survey (HOS; NCT03292887), a global disease registry. In total, 15 female patients were identified, representing 1.1% of the total patients in HOS. The median ages at first symptom onset and diagnosis were 1.8 and 3.1 years, respectively. A total of 8/14 (57.1%) of patients had cognitive impairment at the latest visit. X-chromosome abnormalities were reported in two patients. Most patients (11/15, 73.3%) had received at least one dose of idursulfase, which was generally well tolerated; no serious adverse events during follow-up were considered treatment-related. Musculoskeletal and ear symptoms were present in all 14 patients with data recorded. Almost all females also experienced neurological, abdominal/gastrointestinal, and pulmonary disease, similar to the symptomatology reported in males. Most patients underwent surgery (41 procedures in 12 patients). Two participants had a male sibling with MPS II who was also enrolled in HOS. Both sibling sets had missense variants and demonstrated several differences in signs/symptoms between the male and female siblings. Notably, only the female siblings displayed cognitive impairment. This report illustrates the disease burden in female patients with MPS II, helping to inform clinicians about the likely prognosis for this extremely rare subgroup of patients.

Glycogen storage disease type IV (GSD IV) is an autosomal recessive disorder caused by pathogenic variants in GBE1, resulting in deficient glycogen branching enzyme (GBE) activity and formation of abnormal glycogen ("polyglucosan"). GSD IV manifests across a spectrum of clinical dimensions-including hepatic, neurologic, muscular, and cardiac involvement-which vary in severity. The early-onset forms, historically referred to as Andersen disease, present at different stages ranging from in utero to adolescence. The adult-onset form, referred to as adult polyglucosan body disease (APBD), typically presents in middle to late adulthood. To date, no epidemiological study of GSD IV has been performed. Understanding the global prevalence of GSD IV is critical to increase disease awareness, improve diagnostic rates, inform therapeutic development, and engage pharmaceutical companies. In collaboration with the Rare Genomes Project at the Broad Institute of MIT and Harvard and the APBD Research Foundation, this study curated variants in GBE1 and calculated prevalence across nine genetic ancestry groups. The estimated global carrier frequency of GSD IV is 1 in 243 individuals, and the global genetic prevalence is 1 in 235 784 individuals. Based on the 2024 world population, the estimated number of affected individuals with GSD IV is approximately 34 800. These estimates highlight a significant underdiagnosis of GSD IV and underscore the urgent need for increased awareness of this metabolic disorder. This model of collaboration between researchers, patient advocacy organizations, and genetic data sharing programs provides a framework for estimating the prevalence of other rare diseases in the global population.

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GM1 gangliosidosis is a lysosomal storage disease (LSD) caused by β-galactosidase deficiency, characterized by the accumulation of gangliosides in various tissues. Among different GM1 forms (infantile form, late-infantile and juvenile form, and late-onset form), the infantile form is the most severe: despite an early clinical onset with rapid neurodegeneration, coarse face, abdominal visceromegaly and skeletal abnormalities, the diagnosis is usually delayed, given the lack of recognized early disease-specific markers. We report the case of a newborn presenting with mild edema of hands and feet, mild transient hypoalbuminemia and isolated hyperphosphatasemia at three weeks of life. The first cardiological evaluation showed mild mitral regurgitation. Despite the absence of neurological symptoms, organomegaly, or a coarse face, the turgid consistency of the limbs, together with mitral regurgitation and persistent hyperphosphatasemia, led to multiorgan investigations with discovery of bilateral cherry-red spots and a beak-shaped lumbar vertebra. The cardiological follow-up revealed a dysplastic mitral valve. In the suspicion of a lysosomal disease, biochemical investigations were planned. An altered profile of urinary oligosaccharides, along with low β-galactosidase activity in leukocytes, led to the diagnosis of infantile GM1 gangliosidosis at 3 months of age. The GLB1 gene analysis confirmed the diagnosis. Genetic testing for GLB1 should be considered in cases of persistent hyperphosphatemia, especially if it is associated with any other clinical indicator of GM1, such as limb edema.

Acid sphingomyelinase deficiency (ASMD), historically known as Niemann-Pick disease, is a rare and potentially fatal lysosomal storage disease caused by pathogenic variants in the sphingomyelin phosphodiesterase 1 (SMPD1) gene, which encodes acid sphingomyelinase (ASM). Deficient ASM activity results in dysregulation of cellular membrane homeostasis and accumulation of sphingomyelin in multiple organs. ASMD spans a broad clinical spectrum, with symptoms varying at presentation depending on age at onset and degree and type of organ/systemic involvement. To describe the diagnostic experience and clinical manifestations of ASMD in Argentina, a national retrospective case series was conducted across seven centers in patients diagnosed between 1988 and 2022. Diagnosis was confirmed by reduced ASM activity, with SMPD1 sequencing performed when possible. Nineteen patients (8 females/11 males; 0-76 years) were identified: Type A (4, 21%), Type B (12, 63%), Type A/B (2, 11%), and one unknown. Average age at symptom onset was 3.9 years, and average age at diagnosis was 11.4 years, corresponding to a diagnostic delay of 7.5 years. All patients presented with hepatosplenomegaly. Anemia (79%), pulmonary involvement (79%), thrombocytopenia (79%), and osteopenia (56%) were also reported in a majority of patients. Two patients were initially misdiagnosed with Gaucher disease. This series highlights the variety of clinical presentations and substantial diagnostic delays associated with ASMD in Argentina. Increasing awareness across specialties is essential to improve disease recognition, reduce time to diagnosis, and prevent misdiagnosis.

Wilson disease (WD) is a rare autosomal recessive disorder. Although hepatic and neurologic manifestations are characterized, long-term cardiac outcomes remain poorly defined. We report the first longitudinal study systematically assessing cardiac symptoms and events over nearly a decade in WD. In 2016, 61 WD patients underwent prospective cardiac evaluation including echocardiography, MRI and 24-h ECG. Nine years later, we re-contacted all surviving participants by telephone and emailed standardized questionnaires. Baseline characteristics of respondents and non-respondents were compared to assess selection bias; mortality data were obtained from family interviews and medical records. Outcomes were available for 31 of 61 patients (27 interviewed, 4 deceased; no cardiac-related deaths) after a mean follow-up of 9.1 years. Respondents did not differ from those lost to follow-up, except for fewer disease exacerbations. General and cardiac health remained unchanged in about half (48% and 52%), worsened in ~40%, and improved in ≤ 15%. Palpitations were frequent (70%), whereas dizziness (26%), syncope (7%), and leg oedema (15%) were infrequent and comparable to general-population estimates. Daily activity was unrestricted in 44%, mildly to moderately restricted in 52% and severely restricted in 4%. Only six patients (22%) remained in routine cardiology care. Baseline imaging, strain, autonomic and laboratory parameters did not predict symptoms at follow-up. Over 9 years, cardiac symptoms in WD were common but mostly mild to moderate. These findings support a symptom-guided cardiological assessment within interdisciplinary care. Whether systematic screening of asymptomatic patients is warranted remains uncertain and requires dedicated prospective study.

Classical homocystinuria (HCU) is an autosomal recessive disorder of methionine metabolism with a wide spectrum of severity and clinical presentation. Timely diagnosis facilitates prompt initiation of treatment, which reduces complications. Our aim was to identify the nature of the first clinical manifestation and time to subsequent diagnosis in our cohort of adults with HCU. This retrospective cross-sectional study was conducted in two tertiary referral centres for adult inherited metabolic disorders in the United Kingdom. Fifty-nine patients with sufficient clinical data for detailed analysis were included. 13/59 patients were detected asymptomatically through newborn or family screening and 46/59 were diagnosed on initial presentation with a clinical manifestation of HCU. For 15/54 (27.8%), the median time between initial presentation and diagnosis was 7 years (IQR, 2-11.9), the commonest first manifestation in the delayed group was lens subluxation (6/15, 40%) followed by venous thromboembolism (5/15, 33.3%) and skeletal deformities (2/15, 13.3%). 15/46 (32.6%) had two or more complications by the time of diagnosis. Lens subluxation is the commonest first manifestation of HCU in the group with delayed diagnosis. Early recognition, expanded screening and enhanced clinician awareness are essential for timely diagnosis and improved outcomes.

Adult Refsum disease (ARD, OMIM #266510) is an autosomal recessive condition, resulting in phytanic acid (PA) accumulation in plasma and tissue. The management of ARD relies on a low PA diet, but the importance of adequate energy and carbohydrate provision in reducing circulating PA levels and preventing metabolic crisis is less well described. Two patients recently diagnosed with ARD initiated on the low PA diet leading to a 65% reduction in circulating PA levels, one case achieving this reduction in 5 months. Four patients already established on the low PA diet for > 10 years experienced a rapid rise in circulating PA levels due to weight loss and/or inadequate carbohydrate intakes, despite adherence to a low PA diet. Circulating PA levels more than doubled in all four of these cases. Implementing dietary interventions to ensure adequate energy, carbohydrates and weight stabilisation resulted in a decrease in circulating PA levels by 47%-84% in the outpatient setting. The reduction in circulating PA occurred within 1.6-5 months. These cases demonstrate that PA restriction, and weight and carbohydrate management have integral roles in ensuring metabolic stability in ARD. This case series highlights that circulating PA levels can be reduced more rapidly with dietary interventions than previously shown in case series of chronic management.

Glycogen storage disease 1b (GSD1b) typically presents in early infancy with poor fasting tolerance, hepatomegaly, and neutropenia. We report two siblings who were diagnosed with GSD1b in adulthood. Both had a normal fasting tolerance throughout childhood and, as adults, were able to fast for at least 16 h without developing hypoglycaemia. The older sibling developed nodular cirrhosis during adolescence. The younger sibling exhibited a more pronounced metabolic phenotype, including hyperuricaemia leading to recurrent gout and nephrolithiasis. He experienced occasional episodes of mild neutropenia that were corrected with empagliflozin treatment. To our knowledge, these represent the first reported patients with GSD1b presenting in adulthood with non-hypoglycaemic complications of the disease and without overt neutropenia or neutrophil dysfunction.

2-oxyglutarate dehydrogenase (OGDH) encodes an E1 component of α-ketoglutarate dehydrogenase complex that plays a pivotal role in the Krebs cycle. Biallelic variants in OGDH have been reported to cause an early-onset neurodevelopmental and mitochondrial disorder. However, monoallelic OGDH variants have not been associated with human disease. Here, we identified de novo c.1909C>T (p.Arg637Trp) and heterozygous c.162T>G (p.Ser54Arg) variants in OGDH in unrelated individuals exhibiting late-onset neurological phenotypes, characterized by cerebellar ataxia, peripheral neuropathy and optic atrophy. In silico protein structure predictions suggest that the p.Arg637Trp mutation might influence protein function. To determine the functional effects of the OGDH variants in vivo, we generated Drosophila models harboring UAS-dOgdh (p.Arg639Trp) and UAS-dOgdh (p.Thr58Arg) mutations, homologous to the human variants. While the mutant OGDH expression did not lead to defects in development, it did lead to age-dependent locomotion defects. Further, we found that p.Arg639Trp mutant leads to defective OGDH activity, while p.Thr58Arg causes abnormal proteolytic cleavage and impaired mitochondrial import. These findings suggest that the variants act as dominant-negative and toxic gain-of-function mutations, respectively. Our data provide evidence that monoallelic OGDH variants are involved in late-onset neurological disease in humans.

Maple syrup urine disease (MSUD) is a rare, autosomal recessive metabolic disorder resulting from a deficiency of the branched-chain α-ketoacid dehydrogenase complex. This leads to the accumulation of branched-chain amino acids and their corresponding ketoacids, causing acute metabolic crises and progressive neurological damage if untreated. The impact of founder variants, high consanguinity, and limited access to metabolic care pose challenges in medically underserved populations, such as in Palestine. We conducted a retrospective analysis of 11 patients from eight Palestinian families referred to the main Metabolic Unit in the West Bank. Clinical data, biochemical profiles, and molecular findings were reviewed to characterize the presentation and outcomes of MSUD. Management strategies, including dietary intervention and liver transplantation, were also evaluated. Acute metabolic crises were the initial presentation in 91% of cases, typically within the first days of life. Diagnostic delay averaged 47 days in families without prior MSUD history, compared to 2.3 days in those with affected siblings. Founder pathogenic variants were identified in multiple unrelated families, reflecting genetic homogeneity due to community structure; novel variants were also detected. Timely diagnosis facilitated early referral and improved outcomes. Patients who underwent liver transplantation, especially when performed early, exhibited favorable developmental trajectories, increased leucine tolerance, and fewer hospitalizations. One participant diagnosed prenatally remained free of metabolic crises until transplantation at age six, with excellent neurocognitive outcomes. This study highlights the importance of integrating prenatal screening and early diagnosis, timely dietary intervention, and liver transplantation to improve MSUD outcomes in resource-limited settings.

Cell trafficking disorders(CTDs) are rare, heterogeneous inherited conditions marked by impaired intracellular transport mechanisms such as vesicular trafficking, cytoskeletal dynamics, and organelle interactions. Although clinical awareness is increasing, CTDs are often underdiagnosed due to phenotypic overlap with mitochondrial, lysosomal, and glycosylation disorders. We retrospectively analyzed 14 pediatric patients with molecularly confirmed CTDs at a single center. Clinical, biochemical, imaging, and genetic findings were reviewed to explore genotype-phenotype relationships and shared clinical features. The cohort included 8 females and 6 males, with a median diagnostic age of 29 months (range: 1-86 months). Common initial symptoms were developmental delay, hypotonia, seizures, and hepatosplenomegaly. MRI abnormalities were noted in 7 patients. Elevated serum lactate and dicarboxylic aciduria were observed in 9 and 6 patients, respectively. Creatine kinase was raised in several cases, prominently in one with TANGO2 deficiency. Elevated AST (n = 12) and ALT (n = 5) indicated mild hepatic involvement. Immunological abnormalities included immunoglobulin deficiency (n = 3) and protein C/S deficiency (n = 4). Recurrently mutated genes were AP4M1 and NPC1 (n = 2 each); others included BSCL2, PACS1, RAB3GAP1, STXBP1, TANGO2, HERC1, KIF1A, ATP1A3, VPS13B, and NLGN3. Two novel variants were identified: AP4M1 c.929 + 1G>T and NPC1 c.145A>T. This case series highlights the clinical and biochemical convergence of genetically diverse CTDs, emphasizing the role of trafficking defects in neurodevelopmental and systemic dysfunction. Expanding diagnostic panels to include trafficking-related genes and adopting a mechanism-based classification may improve early recognition and tailored management of these complex disorders.

Sialidosis, also known as Mucolipidosis Type I, is a rare condition caused by defects in the NEU1 gene which causes the accumulation of sialylated peptides, oligosaccharides, and glycoproteins leading to neurological decline. Haematopoetic stem cell transplantation has been performed in the symptomatic phase twice in the literature but has failed to prevent deterioration. We report on a case where a 4-year-old child was diagnosed with pre-symptomatic sialidosis due to investigation following the incidental detection of a cherry-red spot prior to the onset of neurological symptoms. We performed haematopoetic stem cell transplantation with a matched unrelated cord blood unit with optimal timing prior to clinical decline, achieving full donor engraftment with a largely uneventful post-transplant recovery followed by a period of relative clinical stability. However, subsequent neurological decline detailed by clinical history and radiological findings has occurred suggesting a lack of disease responsiveness to transplantation despite optimal timing. We go on to provide supporting laboratory investigations detailing sialidosis fibroblast culture as part of a novel cross-correction assay and compare results to other transplant responsive lysosomal storage disorders such as mucopolysaccharidosis type 1-H and detail a lack of cross-correction in concordance with our clinical findings. We conclude that conventional allogeneic haematopoetic stem cell transplantation is not a viable disease-modifying treatment option in sialidosis, even when performed optimally in the pre-symptomatic phase, and suggest that alternative treatment options must be explored to improve outcomes in this condition.

Hyperammonemic crisis (HAC) remains a major risk factor for urea cycle disorders (UCD), and practical outpatient predictors are limited. We tested whether short-term changes in plasma glutamine (&#x394;Gln) and ammonia (&#x394;NH3) predict HAC and whether effects differ by onset type. In a retrospective cohort (2014-2024) of 18 patients with UCD (neonatal-onset [NO] nine; late-onset [LO] nine), HAC was defined as ammonia (NH3) >&#x2009;150 &#x3bc;g/dL (88.1 &#x3bc;mol/L). For each patient, &#x394;Gln and &#x394;NH3 were calculated between sequential outpatient samples. Investigation 1 compared the changes observed between 31-60&#x2009;days and 8-30&#x2009;days before HAC, with stable period changes. Investigation 2 compared changes at 61-90 and 31-60&#x2009;days before HAC with stable period changes. Associations were evaluated using generalized linear mixed-effects models with onset-specific effects. In NO, larger &#x394;Gln during Investigation 1 was associated with higher HAC risk (p&#x2009;<&#x2009;0.001) whereas &#x394;NH3 was not associated with HAC (p&#x2009;=&#x2009;0.361). The probability of HAC in NO was estimated to reach 67.1% at &#x394;Gln +500 &#x3bc;mol/L. In LO, neither &#x394;Gln nor &#x394;NH3 during Investigation 1 showed a significant association with HAC, and the estimated probabilities remained low across the observed ranges. During Investigation 2, no significant associations between biomarkers and HAC were observed in either group. Progressive increases in plasma glutamine levels within the 31-60 and 8-30&#x2009;days pre-HAC window may serve as early markers of HAC risk in NO-UCD, supporting the utility of longitudinal monitoring. These trends were not associated with LO-UCD, suggesting the need for alternative surveillance strategies tailored to the onset phenotype.

COASY protein associated neurodegeneration is a rare, progressive autosomal recessive neuroferritinopathy due to pathogenic mutations in the COASY gene, coding for the mitochondrial located coenzyme A synthase. Clinical manifestations include seizures, progressive spasticity, dystonia, neuropathy, cognitive decline and neuropsychiatric abnormalities. Both foetal and childhood onset phenotypes are described. We report three patients with COASY protein associated neurodegeneration who were identified on newborn screening with a dried bloodspot acylcarnitine pattern consistent with carnitine palmitoyltransferase 1a deficiency, that is, an elevated ratio of free carnitine (C0) to the sum of palmitoylcarnitine (C16) and octanoylcarnitine (C18):[C0/(C16+C18)]. Two siblings, who died in infancy, displayed neurological features from birth, with magnetic resonance imaging of the brain displaying immature cortical sulcation, parenchymal atrophy and pontocerebellar hypoplasia. The third patient presented with global developmental delay, pyramidal signs and seizures with brain magnetic resonance imaging at age 15&#x2009;months demonstrating a thin corpus callosum, symmetric diffusion restriction throughout the basal ganglia and evidence of deposition in the globus pallidus. This report demonstrates that phenotypes of COASY protein associated neurodegeneration should be included in the differential diagnosis of dried blood spot acylcarnitine pattern suggestive of carnitine palmitoyltransferase 1a deficiency and may represent new potential for early diagnosis.

Pyridox(am)ine 5' Phosphate Oxidase deficiency (PNPO) presents with refractory epilepsy responsive to treatment with pyridoxal 5' phosphate (PLP) or pyridoxine. A 15-year-old boy with PNPO deficiency and cirrhosis underwent orthotopic liver transplantation for hepatocellular carcinoma without extra-hepatic disease. Pre-transplant, the boy was cognitively normal with well controlled epilepsy on PLP 50&#x2009;mg/kg/day. Continuous EEG monitoring was used pre-operatively and post-operatively to identify encephalopathy resulting from PLP deficiency. B6 vitamers (pyridoxine [PN], pyridoxamine [PM], pyridoxal [PL] and phosphorylated forms [PNP, PMP, PLP]) were assayed at times of encephalopathy (symptoms and/or EEG) and for pharmacokinetics. Doses of PLP were titrated to prevent encephalopathy and limit side effects. The intraoperative/immediate postoperative periods were managed with intravenous PLP at a dose which could be reduced to 7.8&#x2009;mg/kg/day before encephalopathy recurred. Post-transplant, transition to oral PLP (100&#x2009;mg/kg/day) led to fulminant hepatic impairment, which improved when IV dosing resumed. Subsequent transition to full oral PLP dosing took 9&#x2009;months with a final dose of 24&#x2009;mg/kg/day oral PLP. PLP showed dose dependent hepatotoxicity with associated rises in alpha-fetoprotein levels. Gradual PLP dose changes and frequent oral dosing minimised encephalopathy episodes and hepato-toxicity. Six years post-transplant, liver biopsy showed moderate portal fibrosis (Ishak fibrosis stage 2/6, LAFSc score 3/9). Encephalopathy/seizures were associated with lower plasma PL concentrations (40 times above physiological levels); but high plasma PLP concentrations did not prevent encephalopathy. Despite liver transplantation, requirements for supraphysiologic doses of PLP continued, suggesting impaired neuronal PLP salvage is the major factor determining PLP requirements in PNPO deficiency.

Incorporating patient preferences into drug development is crucial, particularly, for rare diseases with significant unmet needs. This study used Best-Worst Scaling type 2 (BWS-2) to explore benefit-risk trade-offs for patients and caregivers in two rare neuromuscular diseases (NMDs), myotonic dystrophy type 1 (DM1), and mitochondrial myopathy (MM). Patients with DM1 and MM, along with caregivers, completed a BWS-2 survey assessing four treatment benefits (muscle strength, energy and endurance, balance, cognition) and two risks (permanent liver damage, temporary blurring of vision). Participants were stratified by disease group and age of onset (<&#x2009;20, &#x2265;&#x2009;20&#x2009;years). A latent class analysis was used to calculate the relative importance of each treatment attribute. Sociodemographic and disease-related data were also collected. A total of 270 participants (DM1 n&#x2009;=&#x2009;143, MM n&#x2009;=&#x2009;127, including 37 caregivers) were included. BWS-2 results revealed a priority for improvements in muscle strength (24%), and energy and endurance (23%) across all groups, with caregivers placing a higher priority on cognition improvements (17%) compared to patients. There were no significant differences between disease groups or by age of onset. This study underscores the importance of patient preferences in drug development for rare NMDs. The consensus on treatment priorities across both diseases suggests that overlapping clinical features can inform and expedite future NMD or rare disease drug development.