Cerebrospinal Fluid Glycine Levels Research Articles

Rare Coexistence of SLC6A9 and TOR1A Gene Mutations in a Neonate Presenting with Hereditary Hyperekplexia and Arthrogryposis Multiplex Congenita: A Case Report with Review of Literature

Background: Neonatal hyperekplexia is a rare nonepileptiform disorder characterized by an exaggerated startle reflex associated with generalized hypertonia. We report a newborn with mutation in the glycinergic inhibition pathway resulting in hyperekplexia, associated with features of arthrogryposis multiplex congenita. Clinical Description: A 3-day-old newborn born at term vaginally cried immediately after birth and presented with lethargy, poor cry, and abnormal clonic movements of all four limbs. On examination, there was hyperreflexia and hypertonia in all four limbs along with dislocation of the right knee joint. Blood investigations, including tandem mass spectrometry, serum ammonia, serum, and cerebrospinal fluid glycine levels, were normal, ruling out inborn errors of metabolism responsible for hyperekplexia and arthrogryposis. The magnetic resonance imaging (MRI) brain and electroencephalogram were normal, while the MRI spine showed kyphosis. The genetic evaluation showed heterozygous missense mutation in exon 6 of the SLC6A9 gene and homozygous mutation in the TOR1A gene, which explained the hyperekplexia and the arthrogryposis multiplex congenita. Management and Outcome: The patient received supportive care. Oral clonazepam and levetiracetam were started in view of hypertonia and clonic spasms. Feeding was given by intragastric tube as he had poor suck–swallow coordination. Conclusions: This case highlights an interesting and extremely rare combination of hereditary hyperekplexia and arthrogryposis multiplex congenita existing together in the same patient, confirmed by the corroborating genetic mutations. Awareness of such conditions among pediatricians is essential to order appropriate genetic evaluations and treatment accordingly.

Pro-cognitive effects of the GlyT1 inhibitor Bitopertin in rodents

N-methyl-D-aspartate-receptor (NMDAR) hypofunction contributes to cognitive impairments in neuropsychiatric disorders such as schizophrenia. Reduced NMDAR signalling can be enhanced by increasing extracellular levels of the NMDAR co-agonist glycine through inhibition of its transporter (GlyT1). This may be one option to improve cognitive deficits or negative symptoms of schizophrenia. In this preclinical study, we aimed at investigating effects of the GlyT1-inhibitor Bitopertin on cognition, social function and motivation.Central target engagement was assessed by Bitopertin-induced changes in glycine levels in rats' cerebrospinal fluid (CSF) and prefrontal cortex (PFC). Behavioural effects of Bitopertin on recognition memory were evaluated using a social-recognition test in rats, while its effects on working memory were tested in a spontaneous alternation task in mice pre-treated with the NMDAR antagonist MK-801. Bitopertin was further investigated using a social interaction test in rats pre-treated with the NMDAR antagonist phencyclidine, and the effects on effortful motivation were explored in progressive ratio tasks in rats.Results show that Bitopertin increased glycine levels in CSF and PFC. Moreover, it enhanced recognition memory and reduced MK-801-induced working memory deficits. By contrast, Bitopertin had no significant effects on PCP-induced social interaction deficits, and it did not alter effort-related responding.Collectively, our data demonstrate that GlyT1 inhibition by Bitopertin increased CSF and extracellular glycine levels and advocated for pro-cognitive effects of GlyT1 inhibition both in intact and NMDAR antagonists-pre-treated rodents. Together, these findings support the use of GlyT1-inhibitors for the treatment of cognitive symptoms in pathologies characterized by NMDR hypofunction, such as schizophrenia.

ITPA‐associated developmental and epileptic encephalopathy: characteristic neuroradiological features with novel clinical and biochemical findings

AbstractDevelopmental and epileptic encephalopathies (DEE) in children have an everexpanding range of rare causes. Mutations in ITPA have been recently described as causative of DEE, but only a small number of patients have been reported so far. We describe two Indian children with novel variants in the ITPA gene. Both patients had characteristic, previously described, neuroradiological findings that helped us suspect this condition even before genetic evaluation. In addition, we present new and rarely reported clinical findings associated with this condition: migrating partial epilepsy, fever‐triggered seizures, movement disorder including oculogyria and dystonic tremor. One of the patients also had high cerebrospinal fluid glycine levels. Both patients had drug‐responsive epilepsy, in contrast to drug‐resistant seizures in previously reported patients. These patients reiterate the utility of awareness of specific neuroradiological findings and subsequent genetic evaluation to help make a precise diagnosis. Our report also extends the clinical spectrum and provides insight into possible biochemical causes for the neuroimaging findings seen in this condition.

GLYT1 encephalopathy: Further delineation of disease phenotype and discussion of pathophysiological mechanisms.

GLYT1 encephalopathy is a form of glycine encephalopathy caused by disturbance of glycine transport. The phenotypic spectrum of the disease has not yet been completely described, as only four unrelated families with the disorder have been reported to date. Common features of affected patients include neonatal hypotonia, respiratory failure, encephalopathy, myoclonic jerks, dysmorphic features, and musculoeskeletal anomalies. All reported affected patients harbor biallelic genetic variants in SLC6A9. SNP array together with Sanger sequencing were performed in a newborn with arthrogryposis and severe neurological impairment. The novel genetic variant c.997delC in SLC6A9 was detected in homozygous state in the patient. At protein level, the predicted change is p.(Arg333Alafs*3), which most probably results in a loss of protein function. The variant cosegregated with the disease in the family. A subsequent pregnancy with ultrasound anomalies was also affected. The proband presented the core phenotypic features of GLYT1 encephalopathy, but also a burst suppression pattern on the electroencephalogram, a clinical feature not previously associated with the disorder. Our results suggest that the appearance of this pattern correlates with higher cerebrospinal fluid glycine levels and cerebrospinal fluid/plasma glycine ratios. A detailed discussion on the possible pathophysiological mechanisms of the disorder is also provided.

The effect of hyperglycinemic treatment in captive-bred Vervet monkeys (Chlorocebus aethiops).

Nonketotic hyperglycinemia (NKH) is a neuro-metabolic disorder caused by a deficiency in the glycine cleavage system (GCS) and glycine transporter 1 (GlyT1). A case of atypical late onset of NKH has been reported in a colony of captive-bred Vervet monkeys. The purpose of this study was to evaluate the effect of sodium benzoate and dextromethorphan in reducing glycine levels in hyperglycinemic monkeys. Twelve captive-bred Vervet monkeys were assigned into three groups consisting of four animals (control, valproate induced and cataract with spontaneous hyperglycinemia). Valproate was used to elevate glycine levels and the induced group was then treated with sodium benzoate and dextromethorphan together with group three to normalise glycine levels in cerebrospinal fluid (CSF) and plasma. Valproate induction elicited changes in phosphate, alkaline phosphatase and platelet count, however, no significant changes in the glycine levels were observed, and this might be due to the individual variability within the group. The treatment intervention was only obtained in the spontaneous group whereby the glycine levels were normalised in CSF and plasma. Therefore, it can be concluded that sodium benzoate and dextromethorphan treatment was effective and beneficial to the hyperglycinemic group.

Noradrenaline, Serotonin, GABA, and Glycine in Cerebrospinal Fluid during Labor Pain: A Cross-Sectional Prospective Study.

Background and Aims The inhibitory pathways that play a role in spinal modulation include local interneurons and descending control. Clinical data regarding the role of these pathways in acute pain is lacking. Accordingly, the aim of this study was to evaluate cerebrospinal fluid (CSF) levels of noradrenaline, serotonin, gamma-aminobutyric acid (GABA), and glycine in parturients with labor pain compared to those without labor pain. Methods One hundred term uncomplicated pregnant women receiving spinal anesthesia for cesarean section were enrolled in this prospective cross-sectional study. CSF noradrenaline, serotonin, GABA, and glycine levels were analyzed by enzyme-linked immunosorbent assay. Labor pain score was assessed by numerical rating scale. Results Median CSF serotonin concentration in parturients with labor pain was significantly lower than in those without pain (p < 0.001). Median CSF glycine level in the labor pain group was significantly higher than in the control group (p < 0.001). There were no significant differences in median CSF level of noradrenaline or GABA between parturients with and without labor pain. Subsequent analysis showed labor pain scores to be negatively correlated with CSF serotonin (r = −0.217, p = 0.04) but positively correlated with CSF glycine (r = 0.415, p < 0.001). Conclusion CSF serotonin and glycine were significantly correlated with labor pain scores. These findings suggest that the serotonergic and glycinergic systems may play a role in spinal modulation of visceral pain.

IMPROVING COGNITIVE FUNCTION IN RODENTS VIA INCREASING GLYCINE LEVELS IN BRAIN BY THE NOVEL GLYCINE TRANSPORTER-1 INHIBITOR BI 425809

Dysfunction of the glutamatergic system related to the NMDA receptor may play an important role in cognitive impairment in Alzheimer’s disease. One approach to counteract this is the extracellular increase of the NMDA receptor co-agonist glycine by glycine transporter-1 (GlyT1) inhibition. Thus, inhibiting GlyT1 has potential for treating memory impairment in Alzheimer’s disease via strengthening glutamatergic neurotransmission. Previous studies with GlyT1-inhibitors show memory-enhancing effects in animals. This study characterizes the potency and selectivity of the novel GlyT1 inhibitor BI 425809 and its effects on glycine increase in rat cerebrospinal fluid (CSF). BI 425809 was also evaluated in two rodent cognition tasks assessing episodic memory and working memory. The molecular potency of BI 425809 for GlyT1 was determined by inhibition of [3H]-glycine uptake in human SK-N-MC cells and rat primary cortical neurons. Selectivity was tested against GlyT2 and other off-targets by uptake and receptor binding assays, respectively. Concentrations of glycine in rat CSF samples collected from cisterna magna following oral administration of BI 425809 were determined by HPLC-MS/MS technique. BI 425809 was tested after oral application in the mouse T-maze spontaneous alternation test and in the social recognition test in naive rats. The IC50 value of BI 425809 on GlyT1 was 4.0 nM in SK-N-MC cells and 4.4 nM in rat primary neurons. BI 425809 demonstrated no relevant activity against GlyT2 (IC50 >10 μM) and 103 off-targets at 10 μM. A dose-dependent increase of glycine in rat CSF was observed. BI 425809 reversed MK-801-induced memory deficits in the mouse T-maze (working memory) and improved memory performance in the rat social recognition task (episodic memory). BI 425809 is a potent and selective GlyT1 inhibitor. Systemic administration of BI 425809 led to an increase in glycine levels in rat CSF demonstrating functional target engagement – i.e. GlyT1 inhibition in the brain – showing that glycine levels in CSF can be used to assess GlyT1 inhibition centrally. This might also be used to evaluate central target engagement in clinical trials. BI 425809 showed memory enhancing effects in animal cognition tests. GlyT1 inhibition may be a potential approach to pharmacologically improve cognition in Alzheimer’s disease.

Pre-therapy and post-therapy MRI and MRS findings in non-ketotic hyperglycinemia

Non-ketotic hyperglycinemia (NKH) is an uncommon metabolic disorder with an autosomal recessive inheritance due to abnormal glycine metabolism. We present the pre-therapy and post-therapy magnetic resonance imaging, biochemical and clinical features of a child with NKH with manifestation in the early neonatal period. The initial diagnosis of NKH was made on the biochemical evidence of elevated cerebrospinal fluid (CSF) glycine levels and CSF: plasma glycine ratio. Pre-therapy magnetic resonance imaging revealed thinned out corpus callosum, intracranial hemorrhages, prominent ventricular system, few cystic changes in bilateral gangliocapsular region and abnormal T2 hyperintensities in the white matter. Magnetic resonance spectroscopy did not reveal glycine peak in our case. Post-therapy, there was clinical improvement and reduction in CSF glycine levels. In the follow up scan, myelination had progressed with residual leukomalacic changes and volume loss of white matter.

An interesting case of antenatal hiccups – a clue aiding a prompt diagnosis of non-ketotic hyperglycinaemia

A term baby returned for a routine neonatal discharge check on her second day of life. On examination was found to be apnoeic and hypotonic. She then had a generalised seizure, terminated by phenobarbitone. Over the course of the next 24 hours she was invasively ventilated having become completely apnoeic. She received treatment for possible sepsis including anti viral treatment. The only positive results yielded from blood testing and imaging were small ventricles on cranial ultrasound and a raised gamma glutamyl transferase. It was noted that the patient was hiccupping and on revisiting the antenatal history her mother commented she had thought her daughter had hiccupped consistently (multiple times every day) from twenty weeks gestation. With this history and her clinical presentation a neurological opinion was sought. Many plasma, urine and cerebrospinal fluid (CSF) investigations were requested. The paired plasma and CSF glycine levels were in a ratio of 0.4 (normal up to 0.06). This confirmed the clinical suspicion of non-ketotic hyperglycinaemia. This baby was referred to a tertiary intensive care unit, for neurological opinion and withdrawal of life support. This case illustrates the importance of a thorough antenatal history when reviewing babies ready for discharge as well as the danger of babies being discharged home prior to being reviewing a formal neonatal check. With the postnatal wards needing beds there is significant pressure to review the babies within the first day of life, many are being discharged before paediatric review. The case also revealed the importance of beginning discussions of possible outcomes including withdrawal of life support and palliation, at a local level before transfer to another centre. The outcome for this baby would not have been different. However, there are babies who potentially have serious pathology that would require prompt investigation, diagnosis and life saving treatment. The practice of babies being discharged before neonatal discharge check needs review. Trainees are often the doctors best positioned to begin breaking bad news but sometimes we can be afraid we are doing it inadequately and shy away from doing so.

Pharmacokinetics and cerebral distribution of glycine administered to rats

High doses of glycine have been reported to improve negative schizophrenic symptoms, suggesting that ingested glycine activates glutamatergic transmission via N-methyl-D-aspartate (NMDA) receptors. However, the pharmacokinetics of administered glycine in the brain has not been evaluated. In the present study, the time- and dose-dependent distributions of administered glycine were investigated from a pharmacokinetic viewpoint. Whole-body autoradiography of radiolabeled glycine was performed, and time-concentration curves for glycine and serine in plasma, cerebrospinal fluid (CSF), and brain tissues were obtained. Furthermore, pharmacokinetic parameters were calculated. For a more detailed analysis, the amount of glycine uptake in the brain was evaluated using the brain uptake index method. Radiolabeled glycine was distributed among periventricular organs in the brain. Oral administration of 2 g/kg of glycine significantly elevated the CSF glycine concentration above the ED50 value for NMDA receptors. The glycine levels in CSF were 100 times lower than those in plasma. Glycine levels were elevated in brain tissue, but with a slower time-course than in CSF. Serine, a major metabolite of glycine, was elevated in plasma, CSF, and brain tissue. Glycine uptake in brain tissue increased in a dose-dependent manner. Time-concentration curves revealed that glycine was most likely transported via the blood-CSF barrier and activated NMDA receptors adjacent to the ventricles. The pharmacokinetic analysis and the brain uptake index for glycine suggested that glycine was transported into brain tissue by passive diffusion. These results provide further insight into the potential therapeutic applications of glycine.

Pitfalls in Measuring Cerebrospinal Fluid Glycine Levels in Infants With Encephalopathy

In encephalopathic infants, cerebrospinal fluid hyperglycinemia and elevated cerebrospinal fluid to plasma glycine ratio are considered pathognomonic of nonketotic hyperglycinemia. To evaluate the significance of cerebrospinal fluid hyperglycinemia and elevated cerebrospinal fluid to plasma glycine ratio in acutely encephalopathic infants, a retrospective chart review of all cases of isolated elevation of cerebrospinal fluid glycine levels at Arkansas Children's Hospital from January 1995 to December 2000 was performed. Twenty-two patients (14 males) were included. The most common diagnosis was hypoxic ischemic encephalopathy (n = 8). Nine patients had elevated cerebrospinal fluid to plasma glycine ratio, which was transient in 7 patients. This study shows that elevated cerebrospinal fluid to plasma glycine ratio can be encountered in a variety of clinical conditions. The significance of this observation in light of the poor prognosis of nonketotic hyperglycinemia and the possible role of glycine in the mechanism of ischemic neuronal injury is addressed.

The relation of cerebrospinal fluid and plasma glycine levels in propionic acidaemia, a ‘ketotic hyperglycinaemia’

The characteristic elevation of plasma glycine concentrations observed in propionic acidaemia (PA) and other 'ketotic hyperglycinaemias' has been attributed to secondary inhibition of the hepatic glycine cleavage system (GCS) by accumulating CoA derivatives of branched-chain amino acid metabolites. In nonketotic hyperglycinaemia (NKH), cerebrospinal fluid (CSF) and plasma glycine levels and their ratio are increased due to primary deficiency of central nervous system (CNS) as well as hepatic GCS. Whether the GCS in the CNS is also inhibited in PA is unclear, as there are scant data available on CSF glycine levels in this disorder. We studied the relation of CSF and plasma glycine levels in 6 paired samples from 4 PA patients, including one PA patient with bacterial meningitis who underwent ventriculoperitoneal shunting and multiple CSF analyses (n = 26). In contrast to the CSF glycine levels which were generally elevated in all four PA patients, the CSF/plasma glycine concentration ratios in paired samples were normal (0.016-0.029), with the exception of a single sample (0.132) with extremely high CSF protein concentration (2010 mg/L) during the course of meningitis indicating a disturbed blood-brain barrier. This finding of normal CSF/plasma glycine ratio in PA suggests that the observed elevations of CSF glycine levels are a reflection of the concurrent hyperglycinaemia resulting from secondary inhibition of hepatic GCS, but that brain GCS is not affected, in contrast to the situation in NKH. The neurological sequelae in PA are therefore unlikely to be related to disturbed glycine metabolism.

Discovery and SAR studies of novel GlyT1 inhibitors

Inhibition of the glycine transporter GlyT1 is a potential strategy for the treatment of schizophrenia. A novel series of GlyT1 inhibitors and their structure–activity relationships (SAR) are described. Members of this series are highly potent and selective transport inhibitors which are shown to elevate glycine levels in cerebrospinal fluid.

Heterozygous GLDC and GCSH gene mutations in transient neonatal hyperglycinemia.

Transient neonatal hyperglycinemia is clinically or biochemically indistinguishable from nonketotic hyperglycinemia at onset. In the case of transient neonatal hyperglycinemia, the elevated plasma and cerebrospinal fluid glycine levels are normalized within 2 to 8 weeks. To elucidate the pathogenesis of transient neonatal hyperglycinemia, we studied three patients by screening mutations in the genes that encode three components of the glycine cleavage system. Heterozygous mutations were identified in all of the three patients, suggesting that transient neonatal hyperglycinemia develops in some heterozygous carriers for nonketotic hyperglycinemia.

Efficacy of Low-dose Dextromethorphan in the Treatment of Nonketotic Hyperglycinemia

Nonketotic hyperglycinemia (NKH) is an inborn error of glycine degradation causing muscular hypotonia, seizures, apnea, and lethargy; it has a poor prognosis. Accumulation of glycine in the brain is thought to cause excessive stimulation of the N-methyl-D-aspartate receptor. Dextromethorphan (DM), an N-methyl-D-aspartate receptor antagonist, in doses of 5 to 35 mg/kg per day has been shown to have beneficial therapeutic effects in some patients with NKH. We report the case of a 1-year-old infant with NKH, seizure disorder, and psychomotor delay who was clinically seizure free during treatment with sodium benzoate, arginine, benzodiazepam, and phenobarbital. Although sodium benzoate normalized serum glycine levels (103 to 125 mumol/L), cerebrospinal fluid glycine levels remained elevated (42 to 47 mumol/L), with epileptiform activity on electroencephalography. The addition of low-dose DM (0.25 mg/kg per day) to the treatment led to improvement of electroencephalographic activity, resolution of nystagmus with increased eye contact, and modest progression of developmental milestones. These data suggest that DM at doses significantly lower than previously reported may be beneficial in some patients with NKH. Treatment with low-dose DM needs further evaluation.

Monitoring of neurotransmitter amino acids by means of an indwelling cisterna magna catheter: A comparison of two rodent models of fulminant liver failure

Alterations of brain and cerebrospinal fluid amino acids have consistently been described in human and experimental fulminant liver failure. To evaluate the significance of such changes in the pathogenesis of hepatic encephalopathy in fulminant liver failure, brain and cerebrospinal fluid amino acids (glutamate, aspartate, GABA, glycine, taurine) were measured at various stages during the development of neurological dysfunction in rats after hepatic devascularization or thioacetamide treatment to induce acute liver failure. To facilitate repetitive removal of cerebrospinal fluid, a technique employing long-term implantation of cisterna magna catheters in conscious, freely moving rats was developed. Brain but not cerebrospinal fluid concentrations of the excitatory amino acids glutamate and aspartate were reduced in both animal models of fulminant liver failure in parallel with deterioration of neurological status. Brain and cerebrospinal fluid GABA levels were not significantly altered. Cerebrospinal fluid glycine levels were increased two to three times in parallel with increasing brain glycine content in the devascularized rat but were unchanged in thioacetamide-induced liver failure, suggesting distinct pathophysiological mechanisms in these two experimental situations. On the other hand, onset of coma in both animal models of fulminant liver failure was accompanied by significantly increased cerebrospinal fluid taurine levels. We suggest that such changes result from taurine release from astrocytes in brain into the extracellular fluid; this is consistent with taurine's role in the regulation of intracellular osmolarity in brain. Sequential measurements of amino acids in the cerebrospinal fluid of small rodents with indwelling cisterna magna catheters adds a useful new approach for exploring the neurobiology of hepatic encephalopathy in fulminant liver failure.

Studies of glycine metabolism and transport in fibroblasts from patients with nonketotic hyperglycinemia.

Glycine transport in both normal and nonketotic hyperglycinemia fibroblasts was shown to occur by a sodium-dependent system. No significant difference could be detected in either the Km's (1.4 to 2.0 mM) or the Vmax's (6.2 to 16 nmole per mg protein per min) of the three control and three patient cell lines. Valine was a weak competitive inhibitor of glycine uptake. Ki's from both groups fell into the 5.6 to 5.8 mM range. Plasma levels of valine of one patient reached a maximum of 0.6 mM following a valine load. Glycine cleavage activity could not be detected in either control or nonketotic hyperglycinemia fibroblast lines. Serine utilization was the same in both nonketotic hyperglycinemia and control lines.