A 9-month-old boy with a history of seizures underwent a neurologic and biochemical-genetic evaluation. The brain MRI results were compatible with a diagnosis of Leigh disease, also known as subacute necrotizing encephalomyelopathy, a rare neurometabolic disorder that affects the central nervous system. The patient had been prescribed several antiepileptic medications, including levetiracetam, lamotrigine, phenobarbital, vigabatrin, and topiramate. Metabolic screening for free amino acids was performed on the child's urine, with concentrations quantified with an automated amino acid analyzer (Hitachi L-8800). This commercially available system couples ion-exchange liquid chromatography with postcolumn ninhydrin derivatization before UV detection. This analysis revealed a very large peak with a retention time consistent with the elution of tryptophan (Fig. 1). The calculated urinary excretion was 125 204 μmol/g creatinine. In addition, the urinary concentrations of γ-aminobutyric acid (GABA),5 β-alanine, β-aminoisobutyric acid, and glutamine were also increased substantially. The concentrations of the remaining amino acids were within their respective reference intervals. For confirmation, we submitted a urine aliquot to an external reference laboratory for analysis by liquid chromatography–tandem mass spectrometry (LC-MS/MS). This analysis revealed a tryptophan excretion of 71 μmol/g creatinine (reference interval, 15–302 μmol/g creatinine). Fig. 1. Chromatogram of the patient's urinary amino acid concentrations as generated by the Hitachi L-8800 automated amino acid analyzer. The increased analyte assigned to tryptophan eluted at 77.22 min. The gross discrepancy in tryptophan concentration between the 2 assays, combined with the increased urinary excretion of GABA, β-alanine, β-aminoisobutyric acid, and glutamine, triggered an inquiry into the potential causes. The patient had a neonatal-onset seizure disorder, hypotonia, a developmental delay, and MRI findings compatible with Leigh disease, but isolated hypertryptophanuria is not a finding for this disorder. In addition, the overall prognosis of patients with Leigh disease is poor. The disease represents the clinical and radiologic expression of a group of inherited disorders of energy metabolism, specifically disorders of oxidative phosphorylation or pyruvate oxidation. The ultimate cause of Leigh …