Test Id : HGEMS

Patient's age is required.

Collection Container/Tube: Red top

Submission Container/Tube: Plastic vial

Specimen Volume: 0.1 mL

Collection Instructions: Centrifuge and aliquot serum into a plastic vial.

If not ordering electronically, complete, print, and send a Biochemical Genetics Test Request (T798) with the specimen.

0.02 mL

Evaluation of patients with an abnormal newborn screen showing elevations of glutarylcarnitine (C5-DC) using serum specimens

Evaluation of patients with abnormal newborn screens showing elevations of C4- acylcarnitine to aid in the differential diagnosis of short chain acyl-CoA dehydrogenase and isobutyryl-CoA dehydrogenase deficiencies

Diagnosis of glutaric acidemia type 1

Aiding in diagnosis of glutaric acidemia type 2

Second-tier newborn screening for follow-up of C4 acylcarnitine and glutarylcarnitine (C5DC) elevations.

Differentiating diagnoses of short-chain Co-A dehydrogenase (SCAD) deficiency, isobutyryl-CoA dehydrogenase (IBDH) deficiency, and ethylmalonic encephalopathy.

Differentiating diagnoses of glutaric acidemia type I (GA-1) and glutaric acidemia type II (GA-2)

Acylcarnitine analysis is included in newborn screening blood tests and is utilized for detection of several inborn errors of metabolism, including fatty acid oxidation disorders (FAOD) and organic acidemias (OA). A limitation of this analytic method is its inability to differentiate between several isomers. Additional testing of 2-hydroxyglutaric acid (2OH-GA), 3-hydroxyglutaric acid (3OH-GA), glutaric acid (GA), methylsuccinic acid (MSA), and ethylmalonic acid (EMA) by liquid chromatography tandem mass spectrometry allows better differentiation among C4 acylcarnitine and glutarylcarnitine/C10-OH isomers.

C4 acylcarnitine represents both butyrylcarnitine and isobutyrylcarnitine and is elevated in short-chain acyl Co-A dehydrogenase (SCAD) deficiency, isobutyryl-CoA dehydrogenase (IBDH) deficiency and ethylmalonic encephalopathy (EE). SCAD deficiency is a condition affecting fatty acid metabolism with reported symptoms of hypoglycemia, lethargy, developmental delays, and failure to thrive; there is controversy on whether a biochemical diagnosis necessarily confers clinical symptoms. IBDH deficiency is characterized by cardiomyopathy, hypotonia, and developmental delays, although many individuals with IBDH deficiency are asymptomatic. EE is a rare progressive encephalopathy associated with hypotonia, seizures, and abnormal movements.

Individuals with SCAD deficiency demonstrate elevated plasma EMA and MSA levels, and individuals with EE show only elevations in EMA, while individuals with IBDH deficiency do not typically have elevations in either EMA or MSA.

Glutarylcarnitine (C5-DC) is elevated in glutaric acidemia type I (GA1) but is not differentiated from C10-OH acylcarnitine. GA1 is caused by a deficiency of glutaryl-CoA dehydrogenase and is characterized by bilateral striatal brain injury leading to dystonia, often a result of acute neurologic crises triggered by illness. Individuals with GA1 typically show elevations of GA and 3OH-GA, even in those considered to be "low excretors."

Glutaric acidemia type II (GA2), also known as multiple acyl-CoA dehydrogenase deficiency (MADD), is caused by defects in either the electron transfer flavoprotein (ETF) or ETF-ubiquinone oxidoreductase. This disease can be severe and is often fatal in the first weeks of life with typical symptoms of hypoglycemia, muscle weakness, metabolic acidosis, dysmorphic features, cardiac defects or arrhythmias, renal cysts, and fatty infiltration of the liver. GA2 can have a milder presentation, also known as ethylmalonic-adipic aciduria, with Reye-like illnesses in childhood, and muscle weakness in childhood and adulthood. In addition to elevations in GA, individuals with GA2 can also show increased EMA, MSA, and 2OH-GA.

The American College of Medical Genetics and Genomics (ACMG) Newborn Screening Work Group published diagnostic algorithms for the follow-up of infants who had a positive newborn screening result. For more information see www.acmg.net.

2-OH Glutaric acid: < or =4.5 nmol/mL

3-OH Glutaric acid: < or =0.7 nmol/mL

Glutaric acid: < or =0.8 nmol/mL

Methylsuccinic acid: < or =0.3 nmol/mL

Ethylmalonic acid: < or =1.5 nmol/mL

Elevations of ethylmalonic acid (EMA) and methylsuccinic acid (MSA) are consistent with a diagnosis of short chain acyl Co-A dehydrogenase (SCAD) deficiency.

Elevation of EMA is consistent with a diagnosis of ethylmalonic encephalopathy.

Normal levels of EMA in the context of elevated C4 is consistent with a diagnosis of isobutyryl-CoA dehydrogenase (IBDH) deficiency.

Elevation of glutaric acid (GA) and 3-hydroxyglutaric acid (3OH-GA) are consistent with a diagnosis of glutaric acidemia type I (GA1).

Elevation of GA, 2-hydroxy glutaric acid (2OH-GA), 3OH-GA, EMA, and MSA are consistent with a diagnosis of glutaric acidemia type II (GA2).

No significant cautionary statements

1. Rinaldo P, Cowan TM, Matern D. Acylcarnitine profile analysis. Genet Med. 2008;10(2):151-156

2. Vockley J, Zschocke J, Knerr I, Vockley C, Michael Gibson KK. Branched chain organic acidurias. In: Valle DL, Antonarakis S, Ballabio A, Beaudet AL, Mitchell GA. eds. The Online Metabolic and Molecular Bases of Inherited Disease. McGraw-Hill; 2019. Accessed March 30, 2023. Available at https://ommbid.mhmedical.com/content.aspx?bookid=2709&sectionid=225085758

3. Frerman FE, Goodman SI. Defects of electron transfer flavoprotein and electron transfer flavoprotein-ubiquinone oxidoreductase: Glutaric acidemia type II. In: Valle DL, Antonarakis S, Ballabio A, Beaudet AL, Mitchell GA, eds. The Online Metabolic and Molecular Bases of Inherited Disease. McGraw-Hill; 2019. Accessed March 30, 2023. Available at https://ommbid.mhmedical.com/content.aspx?bookid=2709&sectionid=225088261

4. Larson A, Goodman S. Glutaric acidemia type 1. In: Adam MP, Mirzaa GM, Pagon RA, et al, eds. GeneReviews [Internet]. University of Washington, Seattle; 2019. Accessed March 30, 2023. Available at www.ncbi.nlm.nih.gov/books/NBK546575/

5. Di Meo I, Lamperti C, Tiranti V. Ethylmalonic encephalopathy. In: Adam MP, Mirzaa GM,, Pagon RA, et al, eds. GeneReviews [Internet]. University of Washington, Seattle; 2017. Accessed March 30, 2023. Available at www.ncbi.nlm.nih.gov/books/NBK453432/

6. Wolfe L, Jethva R, Oglesbee D, Vockley J. Short-chain acyl-CoA dehydrogenase deficiency. In: Adam MP, Mirzaa GM, Pagon RA, et al. eds. GeneReviews [Internet]. University of Washington, Seattle; 2011. Updated August 9, 2018. Accessed March 30, 2023. Available at www.ncbi.nlm.nih.gov/books/NBK63582/

An aqueous internal standard is added to the specimen. The supernatant is evaporated under heated nitrogen, and the residue is then reconstituted prior to injection onto a liquid chromatography tandem mass spectrometry (LC-MS/MS). The MS/MS is operated in the multiple reaction monitoring (MRM) negative mode to follow the precursor to product species transitions. Separation of the structural isomers 2-hydroxyglutaric acid (2OH-GA) and 3-hydroxyglutaric acid (3OH-GA) as well as glutaric acid (GA), methylsuccinic acid (MSA), and ethylmalonic acid (EMA) is accomplished by the optimization of the LC separation. The ratios of the extracted peak areas of GA, EMA, and MSA to their respective internal standards as determined by LC-MS/MS are used to calculate the concentration of each analyte in the sample.(Unpublished Mayo method)

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This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. It has not been cleared or approved by the US Food and Drug Administration.

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