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<div class="action-panel-control-wrap">
<label for="email-citation-format" class="action-panel-label">
Format:
</label>
<select id="email-citation-format" name="citation-format" class="action-panel-selector email-citation-format">
<option selected="selected" value="summary">Summary</option>
<option value="summary-text">Summary (text)</option>
<option value="abstract">Abstract</option>
<option value="abstract-text">Abstract (text)</option>
</select>
</div>
<div class="include-supplemental-container">
<input type="checkbox" aria-label="Include MeSH and other data" name="include-supplemental" id="email-include-supplemental" class="email-include-supplemental">
<label for="email-include-supplemental" class="email-include-supplemental-label">MeSH and other data</label>
</div>
<div class="form-field recaptcha ">
<div class="g-recaptcha" id="id-recaptcha" data-sitekey="6LfsWHMdAAAAAClKbtOpjQ2pMjgsGxvv7NdZW9uI"></div>
</div>
<div id="captcha-error-message" class="usa-input-error-message captcha-validation-message" role="alert"></div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Sending..."
data-ga-category="save_share"
data-ga-action="email"
data-ga-label="send">
Send email
</button>
<button class="action-panel-cancel"
aria-label="Close 'Email citations' panel"
ref="linksrc=close_email_panel"
aria-controls="email-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="email"
data-ga-label="cancel">
Cancel
</button>
</div>
<input type="hidden" name="email-search-details" value="" />
<input type="hidden" name="email-search-details-hash" value="0e42663a6c3bd85498fcb88798998fed7bfdc45d457db35281e41afe13cc0524" />
</form>
</div>
</div>
<div id="collections-action-panel"
class="collections-action-panel action-panel in-progress-dots-panel"
aria-hidden="true"
data-collections-open-panel-enabled="false"
data-collections-open-panel-url-hash="#open-collections-panel">
<div class="inner-wrap">
<h3 class="action-panel-heading">
Add to Collections
</h3>
<form id="collections-action-panel-form"
class="collections-action-panel-form action-panel-content action-form action-panel-smaller-selectors"
data-existing-collections-url="/list-existing-collections/"
data-add-to-existing-collection-url="/add-to-existing-collection/"
data-create-and-add-to-new-collection-url="/create-and-add-to-new-collection/"
data-get-article-ids-by-search-url="/get-article-ids-by-search/"
data-myncbi-max-collection-name-length="100"
data-add-to-collection-max-amount="1000"
data-collections-root-url="https://www.ncbi.nlm.nih.gov/myncbi/collections/">
<input type="hidden" name="csrfmiddlewaretoken" value="54wZufraDCh90sHZH8Z7FRXKHQ6wsMiRmRg475Uwdd4DUTNPkrC99ZtofUOIlnQb">
<div class="choice-group" role="radiogroup">
<ul class="radio-group-items">
<li>
<input type="radio"
id="collections-action-panel-new"
class="collections-new"
name="collections"
value="new"
data-ga-category="save_share"
data-ga-action="collections"
data-ga-label="collections_radio_new">
<label for="collections-action-panel-new">Create a new collection</label>
</li>
<li>
<input type="radio"
id="collections-action-panel-existing"
class="collections-existing"
name="collections"
value="existing"
checked="true"
data-ga-category="save_share"
data-ga-action="collections"
data-ga-label="collections_radio_existing">
<label for="collections-action-panel-existing">Add to an existing collection</label>
</li>
</ul>
</div>
<div class="controls-wrapper">
<div class="action-panel-control-wrap new-collections-controls">
<label for="collections-action-panel-add-to-new" class="action-panel-label required-field-asterisk">
Name your collection:
</label>
<input
type="text"
name="add-to-new-collection"
id="collections-action-panel-add-to-new"
class="collections-action-add-to-new"
pattern="[^&quot;&amp;=&lt;&gt;\/]*" title="The following characters are not allowed in the Name field: &quot;&amp;=&lt;&gt;/"
maxlength="100"
data-ga-category="save_share"
data-ga-action="create_collection"
data-ga-label="non_favorties_collection">
<div class="collections-new-name-too-long usa-input-error-message selection-validation-message">
Name must be less than 100 characters
</div>
</div>
<div class="action-panel-control-wrap existing-collections-controls">
<label for="collections-action-panel-add-to-existing" class="action-panel-label">
Choose a collection:
</label>
<select id="collections-action-panel-add-to-existing"
class="action-panel-selector collections-action-add-to-existing"
data-ga-category="save_share"
data-ga-action="select_collection"
data-ga-label="($('#collections-action-add-to-existing').val() === 'Favorites') ? 'Favorites' : 'non_favorites_collection'">
</select>
<div class="collections-retry-load-on-error usa-input-error-message selection-validation-message">
Unable to load your collection due to an error<br>
<a href="#">Please try again</a>
</div>
</div>
</div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Adding..."
data-pinger-ignore
data-ga-category="save_share"
data-ga-action="collections"
data-ga-label="add">
Add
</button>
<button class="action-panel-cancel"
aria-label="Close 'Add to Collections' panel"
ref="linksrc=close_collections_panel"
aria-controls="collections-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="collections"
data-ga-label="cancel">
Cancel
</button>
</div>
</form>
</div>
</div>
<div id="bibliography-action-panel"
class="bibliography-action-panel action-panel in-progress-dots-panel"
aria-hidden="true"
data-bibliography-open-panel-enabled="false"
data-bibliography-open-panel-url-hash="#open-bibliography-panel">
<div class="inner-wrap">
<h3 class="action-panel-heading">
Add to My Bibliography
</h3>
<form id="bibliography-action-panel-form"
class="bibliography-action-panel-form action-panel-content action-form action-panel-smaller-selectors"
data-add-to-bibliography-max-amount="100"
data-add-to-bibliography-batch-size="10"
data-bibliography-delegates-url="/list-bibliography-delegates/"
data-add-to-bibliography-url="/add-to-bibliography/"
data-get-article-ids-by-search-url="/get-article-ids-by-search/"
data-mybib-root-url="https://www.ncbi.nlm.nih.gov/myncbi/collections/mybibliography/">
<input type="hidden" name="csrfmiddlewaretoken" value="54wZufraDCh90sHZH8Z7FRXKHQ6wsMiRmRg475Uwdd4DUTNPkrC99ZtofUOIlnQb">
<div class="action-panel-control-wrap bibliographies-controls">
<div class="choice-group">
<ul class="bibliographies-action-add radio-group-items">
<li>
<input name="bibliography" id="my-bibliography" class="my-bibliography" type="radio" checked/>
<label for="my-bibliography">My Bibliography</label>
</li>
</ul>
</div>
</div>
<div class="bibliographies-retry-load-on-error usa-input-error-message selection-validation-message">
Unable to load your delegates due to an error<br>
<a href="#">Please try again</a>
</div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Adding..."
data-pinger-ignore>
Add
</button>
<button class="action-panel-cancel"
aria-label="Close 'Add to bibliography' panel"
ref="linksrc=close_bibliography_panel"
aria-controls="bibliography-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="mybib"
data-ga-label="cancel">
Cancel
</button>
</div>
</form>
</div>
</div>
<div id="saved-search-action-panel" class="saved-search-action-panel action-panel " aria-hidden="true"
data-saved-search-open-panel-enabled="false"
data-saved-search-open-panel-url-hash="#open-saved-search-panel">
<div class="inner-wrap">
<h2 class="action-panel-heading">
Your saved search
</h2>
<form id="saved-search-action-panel-form"
class="saved-search-action-panel-form action-panel-content action-form"
data-create-saved-search-url="/create-saved-search/"
data-try-search-terms-url="/try-search-term/"
data-saved-search-root-url="https://www.ncbi.nlm.nih.gov/myncbi/searches/">
<input type="hidden" name="csrfmiddlewaretoken" value="54wZufraDCh90sHZH8Z7FRXKHQ6wsMiRmRg475Uwdd4DUTNPkrC99ZtofUOIlnQb">
<div class="action-panel-control-wrap">
<label for="saved-search-name" class="action-panel-label saved-search-name-label required-field-asterisk">
Name of saved search:
</label>
<input maxlength="200"
type="text"
name="saved-search-name"
id="saved-search-name"
class="saved-search-name"
value=""
required
pattern="[^&quot;&amp;=&lt;&gt;\/]*" title="The following characters are not allowed in the Name field: &quot;&amp;=&lt;&gt;/">
</div>
<div class="action-panel-control-wrap">
<label for="saved-search-term" class="action-panel-label required-field-asterisk">
Search terms:
</label>
<textarea name="saved-search-term" id="saved-search-term" class="saved-search-term" required></textarea>
</div>
<div class="test-search-term-wrap">
<a href="#" class="try-search-term">Test search terms</a>
</div>
<div class="choice-group action-panel-extra-margin-top">
<span class="action-panel-label" id="fieldset-label">
Would you like email updates of new search results?
</span>
<fieldset id="saved-search-alert" aria-describedby="fieldset-label">
<legend class="usa-sr-only">Saved Search Alert Radio Buttons</legend>
<ul class="radio-group-items">
<li>
<input type="radio" id="saved-search-alert-yes" class="saved-search-alert-yes" name="saved-search-alert" value="yes" checked>
<label for="saved-search-alert-yes" class="action-panel-label">Yes</label>
</li>
<li>
<input aria-label="No radio input" type="radio" id="saved-search-alert-no" class="saved-search-alert-no" name="saved-search-alert" value="no">
<label for="saved-search-alert-no" class="action-panel-label">No</label>
</li>
</ul>
</fieldset>
</div>
<div class="alert-schedule-wrap">
<div class="action-panel-control-wrap">
<label class="action-panel-label">
Email:
</label>
<span aria-label="Email address" id="saved-search-email" class="action-panel-label"><span class="action-panel-label-bold"></span> (<a class="myncbi-account-settings" href="https://www.ncbi.nlm.nih.gov/account/settings/">change</a>)</span>
</div>
<div class="action-panel-control-wrap action-panel-extra-margin-top">
<label for="saved-search-frequency" class="action-panel-label">
Frequency:
</label>
<select id="saved-search-frequency" class="no-border-panel-selector saved-search-frequency">
<option value="monthly">Monthly</option>
<option value="weekly">Weekly</option>
<option value="daily">Daily</option>
</select>
</div>
<div class="action-panel-control-wrap saved-search-monthly-additional">
<label for="saved-search-monthly-on-day" class="action-panel-label">
Which day?
</label>
<select id="saved-search-monthly-on-day" class="no-border-panel-selector">
<option value="Sunday">The first Sunday</option>
<option value="Monday">The first Monday</option>
<option value="Tuesday">The first Tuesday</option>
<option value="Wednesday">The first Wednesday</option>
<option value="Thursday">The first Thursday</option>
<option value="Friday">The first Friday</option>
<option value="Saturday">The first Saturday</option>
<option value="day">The first day</option>
<option value="weekday">The first weekday</option>
</select>
</div>
<div class="action-panel-control-wrap saved-search-weekly-additional">
<label for="saved-search-weekly-on-day" class="action-panel-label">
Which day?
</label>
<select id="saved-search-weekly-on-day" class="no-border-panel-selector saved-search-weekly-on-day">
<option value="Sunday">Sunday</option>
<option value="Monday">Monday</option>
<option value="Tuesday">Tuesday</option>
<option value="Wednesday">Wednesday</option>
<option value="Thursday">Thursday</option>
<option value="Friday">Friday</option>
<option value="Saturday">Saturday</option>
</select>
</div>
<div class="action-panel-control-wrap">
<label for="saved-search-report" class="action-panel-label">
Report format:
</label>
<select id="saved-search-report" class="no-border-panel-selector saved-search-report">
<option value="DocSum">Summary</option>
<option value="DocSumText">Summary (text)</option>
<option value="Abstract">Abstract</option>
<option value="AbstractText">Abstract (text)</option>
<option value="MEDLINE">PubMed</option>
</select>
</div>
<div class="action-panel-control-wrap">
<label for="saved-search-amount" class="action-panel-label">
Send at most:
</label>
<select id="saved-search-amount" class="no-border-panel-selector saved-search-amount">
<option value="1">1 item</option>
<option value="5" selected>5 items</option>
<option value="10">10 items</option>
<option value="20">20 items</option>
<option value="50">50 items</option>
<option value="100">100 items</option>
<option value="200">200 items</option>
</select>
</div>
<div>
<input type="checkbox" id="saved-search-send-if-no-result" class="saved-search-send-if-no-result" name="saved-search-send-if-no-result">
<label for="saved-search-send-if-no-result" class="action-panel-label smaller-checkbox">
Send even when there aren't any new results
</label>
</div>
<div class="action-panel-control-wrap option-text-in-email-wrap">
<label for="saved-search-email-text" class="action-panel-label">
Optional text in email:
</label>
<textarea name="saved-search-email-text"
id="saved-search-email-text"
class="saved-search-email-text"></textarea>
</div>
</div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Saving..."
data-ga-category="save_share"
data-ga-action="alert"
data-ga-label="save">
Save
</button>
<button class="action-panel-cancel"
aria-label="Close 'Your saved search' panel"
ref="linksrc=close_saved_search_panel"
aria-controls="saved-search-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="alert"
data-ga-label="cancel">
Cancel
</button>
</div>
</form>
</div>
</div>
<div id="citation-manager-action-panel" class="citation-manager-action-panel action-panel" aria-hidden="true">
<div class="inner-wrap">
<h2 class="action-panel-heading">
Create a file for external citation management software
</h2>
<form id="citation-manager-action-panel-form"
class="action-panel-content action-form"
action="/results-export-ids/"
data-by-search-action="/results-export-search-data/"
data-by-ids-action="/results-export-ids/"
method="post"
data-by-search-method="post"
data-by-ids-method="post">
<input type="hidden" name="csrfmiddlewaretoken" value="54wZufraDCh90sHZH8Z7FRXKHQ6wsMiRmRg475Uwdd4DUTNPkrC99ZtofUOIlnQb">
<input name="results-format" type="hidden" value="pubmed"/>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Sending..."
data-ga-category="save_share"
data-ga-action="citation_manager"
data-ga-label="save">
Create file
</button>
<button class="action-panel-cancel"
aria-label="Close 'Send citations to citation manager' panel"
ref="linksrc=close_citation_manager_panel"
aria-controls="citation-manager-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="citation_manager"
data-ga-label="cancel">
Cancel
</button>
</div>
</form>
</div>
</div>
<div id="rss-action-panel" class="rss-action-panel action-panel " aria-hidden="true">
<div class="inner-wrap">
<h2 class="action-panel-heading">
Your RSS Feed
</h2>
<form id="rss-action-panel-form"
class="rss-action-panel-form action-panel-content action-form"
data-create-rss-feed-url="/create-rss-feed-url/"
data-search-form-term-value="">
<input type="hidden" name="csrfmiddlewaretoken" value="54wZufraDCh90sHZH8Z7FRXKHQ6wsMiRmRg475Uwdd4DUTNPkrC99ZtofUOIlnQb">
<div class="action-panel-control-wrap">
<label for="rss-name" class="action-panel-label required-field-asterisk">
Name of RSS Feed:
</label>
<input maxlength="200"
placeholder="Name"
type="text"
name="rss-name"
id="rss-name"
class="rss-name"
value=''
required
pattern="[^&quot;&amp;=&lt;&gt;\/]*" title="The following characters are not allowed in the Name field: &quot;&amp;=&lt;&gt;/">
</div>
<div class="rss-limit-wrap">
<div class="action-panel-control-wrap action-panel-extra-margin-top">
<label for="rss-limit" class="action-panel-label">
Number of items displayed:
</label>
<select id="rss-limit" class="no-border-panel-selector rss-limit">
<option value="5">5</option>
<option value="10">10</option>
<option value="15" selected="selected">15</option>
<option value="20">20</option>
<option value="50">50</option>
<option value="100">100</option>
</select>
</div>
</div>
<div class="action-panel-actions">
<button class="action-panel-submit"
type="submit"
data-loading-label="Creating..."
data-ga-category="save_share"
data-ga-action="alert"
data-ga-label="save">
Create RSS
</button>
<button class="action-panel-cancel"
aria-label="Close 'Your RSS' panel"
ref="linksrc=close_rss_panel"
aria-controls="rss-action-panel"
aria-expanded="false"
data-ga-category="save_share"
data-ga-action="alert"
data-ga-label="cancel">
Cancel
</button>
</div>
<div class="action-panel-control-wrap rss-link-copy-wrap">
<label for="rss-link" class="usa-sr-only">RSS Link</label>
<input placeholder="Your RSS Feed Link" type="text" name="rss-link" id="rss-link" class="rss-link" title="RSS Link">
<button
type="button"
disabled
class="rss-link-copy-button disabled"
data-ga-category="save_share"
data-ga-action="rss"
data-ga-label="copy">
Copy
</button>
</div>
</form>
</div>
</div>
</div>
</div>
<div class="article-page" id="article-page" data-article-pmid="26081110">
<aside class="page-sidebar">
<div class="inner-wrap">
<div class="full-text-links">
<div class="full-view">
<h3 class="title">
Full text links
</h3>
<div class="full-text-links-list">
<a class="link-item
dialog-focus"
href="https://ojrd.biomedcentral.com/articles/10.1186/s13023-015-0290-1"
target="_blank"
rel="noopener"
ref="linksrc=fulltextorjournal_fulltext&amp;is_pmc=False&amp;PrId=3196&amp;itool=Abstract-def&amp;log$=linkouticon&amp;uid=26081110&amp;db=pubmed&amp;nlmid=101266602"
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BioMed Central
</span></a><a class="link-item
pmc
"
href="https://pmc.ncbi.nlm.nih.gov/articles/pmid/26081110/"
target="_blank"
rel="noopener"
ref="linksrc=fulltextorjournal_fulltext&amp;is_pmc=True&amp;PrId=3494&amp;itool=Abstract-def&amp;log$=linkouticon&amp;uid=26081110&amp;db=pubmed&amp;nlmid=101266602"
title="Free full text at PubMed Central"
data-ga-category="full_text"
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data-ga-label="26081110"
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Free PMC article
</span></a>
</div>
</div>
<div class="short-view">
<a href="#" class="full-text-links-button full-text-links-dialog-trigger">
Full text links
</a>
</div>
</div>
<div class="actions-buttons sidebar"><h3 class="title">Actions</h3><div class="inner-wrap"><button class="citation-button citation-dialog-trigger"
aria-label="Open dialog with citation text in different styles"
data-ga-category="save_share"
data-ga-action="cite"
data-ga-label="open"
data-all-citations-url="/26081110/citations/"
data-citation-style="nlm"
data-pubmed-format-link="/26081110/export/"><span class="button-label">Cite</span></button><link type="text/css" href="ncbi-overlay-block/src/overlay-block.css"><div class="collections-button-container" data-article-id="26081110" data-article-db="pubmed"><button class="collections-button collections-dialog-trigger"
aria-label="Save article in MyNCBI collections."
data-ga-category="collections_button"
data-ga-action="click"
data-ga-label="collections_button"
data-collections-open-dialog-enabled="false"
data-collections-open-dialog-url="https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F26081110%2F%23open-collections-dialog"
data-in-collections="false"><span class="button-label">Collections</span></button><div class="overlay" role="dialog"><div id="collections-action-dialog"
class="dialog collections-dialog"
aria-hidden="true"><div class="title">Add to Collections</div><div class="collections-action-panel action-panel"><form id="collections-action-dialog-form"
class="collections-action-panel-form action-panel-content action-form action-panel-smaller-selectors"
data-existing-collections-url="/list-existing-collections/"
data-add-to-existing-collection-url="/add-to-existing-collection/"
data-create-and-add-to-new-collection-url="/create-and-add-to-new-collection/"
data-myncbi-max-collection-name-length="100"
data-collections-root-url="https://www.ncbi.nlm.nih.gov/myncbi/collections/"><input type="hidden" name="csrfmiddlewaretoken" value="54wZufraDCh90sHZH8Z7FRXKHQ6wsMiRmRg475Uwdd4DUTNPkrC99ZtofUOIlnQb"><div class="choice-group" role="radiogroup"><ul class="radio-group-items"><li><input type="radio"
id="collections-action-dialog-new"
class="collections-new"
name="collections"
value="new"
data-ga-category="collections_button"
data-ga-action="click"
data-ga-label="collections_radio_new"><label for="collections-action-dialog-new">Create a new collection</label></li><li><input type="radio"
id="collections-action-dialog-existing"
class="collections-existing"
name="collections"
value="existing"
checked="true"
data-ga-category="collections_button"
data-ga-action="click"
data-ga-label="collections_radio_existing"><label for="collections-action-dialog-existing">Add to an existing collection</label></li></ul></div><div class="controls-wrapper"><div class="action-panel-control-wrap new-collections-controls"><label for="collections-action-dialog-add-to-new" class="action-panel-label required-field-asterisk">
Name your collection:
</label><input
type="text"
name="add-to-new-collection"
id="collections-action-dialog-add-to-new"
class="collections-action-add-to-new"
pattern="[^&quot;&amp;=&lt;&gt;\/]*" title="The following characters are not allowed in the Name field: &quot;&amp;=&lt;&gt;/"
maxlength="100"
data-ga-category="collections_button"
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Clinical and biochemical characterization of four patients with mutations in ECHS1
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><sup class="key">9</sup> Departments of Genetics and Pediatrics, Case Western Reserve University, Cleveland, OH, 44106, USA. Jirair.Bedoyan@UHhospitals.org.</li>
<li data-affiliation-id="full-view-affiliation-10"
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><sup class="key">10</sup> Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands. f.m.vaz@amc.nl.</li>
<li data-affiliation-id="full-view-affiliation-11"
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><sup class="key">11</sup> Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands. h.r.waterham@amc.nl.</li>
<li data-affiliation-id="full-view-affiliation-12"
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><sup class="key">12</sup> Department of Biochemistry and Molecular Genetics, University of Colorado, Aurora, CO, 80045, USA. Katherine.Gowan@ucdenver.edu.</li>
<li data-affiliation-id="full-view-affiliation-13"
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><sup class="key">13</sup> Department of Pediatrics, Section of Genetics, University of Colorado, Aurora, CO, 80045, USA. Kathryn.Chatfield@ucdenver.edu.</li>
<li data-affiliation-id="full-view-affiliation-14"
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><sup class="key">14</sup> Department of Pediatrics, Section of Pediatric Cardiology, University of Colorado, Aurora, CO, 80045, USA. Kathryn.Chatfield@ucdenver.edu.</li>
<li data-affiliation-id="full-view-affiliation-15"
id="full-view-affiliation-15"
><sup class="key">15</sup> Department of Pathology &amp; Laboratory Medicine, Children&#x27;s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U74SA, USA. kormanikk@email.chop.edu.</li>
<li data-affiliation-id="full-view-affiliation-16"
id="full-view-affiliation-16"
><sup class="key">16</sup> Department of Pathology &amp; Laboratory Medicine, Children&#x27;s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U74SA, USA. bennettmi@email.chop.edu.</li>
<li data-affiliation-id="full-view-affiliation-17"
id="full-view-affiliation-17"
><sup class="key">17</sup> Monique and Jacques Roboh Department of Genetic Research, Hadassah, Hebrew University Medical Center, Jerusalem, Israel. elpeleg@hadassah.org.il.</li>
<li data-affiliation-id="full-view-affiliation-18"
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><sup class="key">18</sup> Department of Pediatrics, Section of Genetics, University of Colorado, Aurora, CO, 80045, USA. Johan.VanHove@childrenscolorado.org.</li>
<li data-affiliation-id="full-view-affiliation-19"
id="full-view-affiliation-19"
><sup class="key">19</sup> Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands. r.j.wanders@amc.nl.</li>
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Clinical and biochemical characterization of four patients with mutations in ECHS1
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<span class="authors-list-item "><span class="full-name">Sacha Ferdinandusse</span><span class="citation-separator">&nbsp;et al.</span></span>
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<span class="authors-list-item "><a class="full-name"
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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data-ga-label="Marisa W Friederich">Marisa W Friederich</a><sup class="affiliation-links"><span class="author-sup-separator">&nbsp;</span><a class="affiliation-link" title="Department of Pediatrics, Section of Genetics, University of Colorado, Aurora, CO, 80045, USA. Marisa.Friederich@ucdenver.edu." href="#short-view-affiliation-2" ref="linksrc=author_aff">
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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data-ga-label="Alberto Burlina">Alberto Burlina</a><sup class="affiliation-links"><span class="author-sup-separator">&nbsp;</span><a class="affiliation-link" title="Department of Paediatrics, Division of Metabolic Diseases, University Hospital of Padua, Padua, Italy. alberto.burlina@unipd.it." href="#short-view-affiliation-3" ref="linksrc=author_aff">
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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4
</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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data-ga-label="Renata C Gallagher">Renata C Gallagher</a><sup class="affiliation-links"><span class="author-sup-separator">&nbsp;</span><a class="affiliation-link" title="Department of Pediatrics, Section of Genetics, University of Colorado, Aurora, CO, 80045, USA. Renata.Gallagher@ucsf.edu." href="#short-view-affiliation-7" ref="linksrc=author_aff">
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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8
</a><span class="author-sup-separator">&nbsp;</span><a class="affiliation-link" title="Departments of Genetics and Pediatrics, Case Western Reserve University, Cleveland, OH, 44106, USA. Jirair.Bedoyan@UHhospitals.org." href="#short-view-affiliation-9" ref="linksrc=author_aff">
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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13
</a><span class="author-sup-separator">&nbsp;</span><a class="affiliation-link" title="Department of Pediatrics, Section of Pediatric Cardiology, University of Colorado, Aurora, CO, 80045, USA. Kathryn.Chatfield@ucdenver.edu." href="#short-view-affiliation-14" ref="linksrc=author_aff">
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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data-ga-label="Kaitlyn Bloom">Kaitlyn Bloom</a><sup class="affiliation-links"><span class="author-sup-separator">&nbsp;</span><a class="affiliation-link" title="Department of Pathology &amp; Laboratory Medicine, Children&#x27;s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U74SA, USA. kormanikk@email.chop.edu." href="#short-view-affiliation-15" ref="linksrc=author_aff">
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</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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data-ga-label="Orly Elpeleg">Orly Elpeleg</a><sup class="affiliation-links"><span class="author-sup-separator">&nbsp;</span><a class="affiliation-link" title="Monique and Jacques Roboh Department of Genetic Research, Hadassah, Hebrew University Medical Center, Jerusalem, Israel. elpeleg@hadassah.org.il." href="#short-view-affiliation-17" ref="linksrc=author_aff">
17
</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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18
</a></sup><span class="comma">,&nbsp;</span></span><span class="authors-list-item "><a class="full-name"
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data-ga-label="Ronald J A Wanders">Ronald J A Wanders</a><sup class="affiliation-links"><span class="author-sup-separator">&nbsp;</span><a class="affiliation-link" title="Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands. r.j.wanders@amc.nl." href="#short-view-affiliation-19" ref="linksrc=author_aff">
19
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<div class="affiliations">
<h3 class="title">
Affiliations
</h3>
<ul class="item-list">
<li data-affiliation-id="short-view-affiliation-1"
id="short-view-affiliation-1"
><sup class="key">1</sup> Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands. s.ferdinandusse@amc.nl.</li>
<li data-affiliation-id="short-view-affiliation-2"
id="short-view-affiliation-2"
><sup class="key">2</sup> Department of Pediatrics, Section of Genetics, University of Colorado, Aurora, CO, 80045, USA. Marisa.Friederich@ucdenver.edu.</li>
<li data-affiliation-id="short-view-affiliation-3"
id="short-view-affiliation-3"
><sup class="key">3</sup> Department of Paediatrics, Division of Metabolic Diseases, University Hospital of Padua, Padua, Italy. alberto.burlina@unipd.it.</li>
<li data-affiliation-id="short-view-affiliation-4"
id="short-view-affiliation-4"
><sup class="key">4</sup> Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands. j.ruiter@amc.uva.nl.</li>
<li data-affiliation-id="short-view-affiliation-5"
id="short-view-affiliation-5"
><sup class="key">5</sup> Department of Pediatrics, Section of Genetics, University of Colorado, Aurora, CO, 80045, USA. Curtis.Coughlin@childrenscolorado.org.</li>
<li data-affiliation-id="short-view-affiliation-6"
id="short-view-affiliation-6"
><sup class="key">6</sup> Department of Pathology, University of Colorado, Aurora, CO, 80045, USA. megan.dishop@childrensmn.org.</li>
<li data-affiliation-id="short-view-affiliation-7"
id="short-view-affiliation-7"
><sup class="key">7</sup> Department of Pediatrics, Section of Genetics, University of Colorado, Aurora, CO, 80045, USA. Renata.Gallagher@ucsf.edu.</li>
<li data-affiliation-id="short-view-affiliation-8"
id="short-view-affiliation-8"
><sup class="key">8</sup> Center for Inherited Disorders of Energy Metabolism (CIDEM), University Hospitals Case Medical Center, Cleveland, OH, 44106, USA. Jirair.Bedoyan@UHhospitals.org.</li>
<li data-affiliation-id="short-view-affiliation-9"
id="short-view-affiliation-9"
><sup class="key">9</sup> Departments of Genetics and Pediatrics, Case Western Reserve University, Cleveland, OH, 44106, USA. Jirair.Bedoyan@UHhospitals.org.</li>
<li data-affiliation-id="short-view-affiliation-10"
id="short-view-affiliation-10"
><sup class="key">10</sup> Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands. f.m.vaz@amc.nl.</li>
<li data-affiliation-id="short-view-affiliation-11"
id="short-view-affiliation-11"
><sup class="key">11</sup> Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands. h.r.waterham@amc.nl.</li>
<li data-affiliation-id="short-view-affiliation-12"
id="short-view-affiliation-12"
><sup class="key">12</sup> Department of Biochemistry and Molecular Genetics, University of Colorado, Aurora, CO, 80045, USA. Katherine.Gowan@ucdenver.edu.</li>
<li data-affiliation-id="short-view-affiliation-13"
id="short-view-affiliation-13"
><sup class="key">13</sup> Department of Pediatrics, Section of Genetics, University of Colorado, Aurora, CO, 80045, USA. Kathryn.Chatfield@ucdenver.edu.</li>
<li data-affiliation-id="short-view-affiliation-14"
id="short-view-affiliation-14"
><sup class="key">14</sup> Department of Pediatrics, Section of Pediatric Cardiology, University of Colorado, Aurora, CO, 80045, USA. Kathryn.Chatfield@ucdenver.edu.</li>
<li data-affiliation-id="short-view-affiliation-15"
id="short-view-affiliation-15"
><sup class="key">15</sup> Department of Pathology &amp; Laboratory Medicine, Children&#x27;s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U74SA, USA. kormanikk@email.chop.edu.</li>
<li data-affiliation-id="short-view-affiliation-16"
id="short-view-affiliation-16"
><sup class="key">16</sup> Department of Pathology &amp; Laboratory Medicine, Children&#x27;s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, U74SA, USA. bennettmi@email.chop.edu.</li>
<li data-affiliation-id="short-view-affiliation-17"
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><sup class="key">17</sup> Monique and Jacques Roboh Department of Genetic Research, Hadassah, Hebrew University Medical Center, Jerusalem, Israel. elpeleg@hadassah.org.il.</li>
<li data-affiliation-id="short-view-affiliation-18"
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><sup class="key">18</sup> Department of Pediatrics, Section of Genetics, University of Colorado, Aurora, CO, 80045, USA. Johan.VanHove@childrenscolorado.org.</li>
<li data-affiliation-id="short-view-affiliation-19"
id="short-view-affiliation-19"
><sup class="key">19</sup> Departments of Clinical Chemistry and Pediatrics, Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, AZ, 1105, The Netherlands. r.j.wanders@amc.nl.</li>
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Abstract
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<p>
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Background:
</strong>
Short-chain enoyl-CoA hydratase (SCEH, encoded by ECHS1) catalyzes hydration of 2-trans-enoyl-CoAs to 3(S)-hydroxy-acyl-CoAs. SCEH has a broad substrate specificity and is believed to play an important role in mitochondrial fatty acid oxidation and in the metabolism of branched-chain amino acids. Recently, the first patients with SCEH deficiency have been reported revealing only a defect in valine catabolism. We investigated the role of SCEH in fatty acid and branched-chain amino acid metabolism in four newly identified patients. In addition, because of the Leigh-like presentation, we studied enzymes involved in bioenergetics.
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Methods:
</strong>
Metabolite, enzymatic, protein and genetic analyses were performed in four patients, including two siblings. Palmitate loading studies in fibroblasts were performed to study mitochondrial β-oxidation. In addition, enoyl-CoA hydratase activity was measured with crotonyl-CoA, methacrylyl-CoA, tiglyl-CoA and 3-methylcrotonyl-CoA both in fibroblasts and liver to further study the role of SCEH in different metabolic pathways. Analyses of pyruvate dehydrogenase and respiratory chain complexes were performed in multiple tissues of two patients.
</p>
<p>
<strong class="sub-title">
Results:
</strong>
All patients were either homozygous or compound heterozygous for mutations in the ECHS1 gene, had markedly reduced SCEH enzymatic activity and protein level in fibroblasts. All patients presented with lactic acidosis. The first two patients presented with vacuolating leukoencephalopathy and basal ganglia abnormalities. The third patient showed a slow neurodegenerative condition with global brain atrophy and the fourth patient showed Leigh-like lesions with a single episode of metabolic acidosis. Clinical picture and metabolite analysis were not consistent with a mitochondrial fatty acid oxidation disorder, which was supported by the normal palmitate loading test in fibroblasts. Patient fibroblasts displayed deficient hydratase activity with different substrates tested. Pyruvate dehydrogenase activity was markedly reduced in particular in muscle from the most severely affected patients, which was caused by reduced expression of E2 protein, whereas E2 mRNA was increased.
</p>
<p>
<strong class="sub-title">
Conclusions:
</strong>
Despite its activity towards substrates from different metabolic pathways, SCEH appears to be only crucial in valine metabolism, but not in isoleucine metabolism, and only of limited importance for mitochondrial fatty acid oxidation. In severely affected patients SCEH deficiency can cause a secondary pyruvate dehydrogenase deficiency contributing to the clinical presentation.
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<p> Fig. 1 </p>
</strong>
<div class="figure-caption-contents"><p> Biochemical pathways. The SCEH enzyme… </p></div>
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<p> Fig. 1 </p>
</strong>
<div class="figure-caption-contents"><p> Biochemical pathways. The SCEH enzyme encoded by the <i> ECHS1 </i> gene is involved in… </p></div>
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Fig. 1
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<div class="figure-caption-contents">Biochemical pathways. The SCEH enzyme encoded by the <i>ECHS1</i> gene is involved in different metabolic pathways. On the <i>left side</i> the pathways of valine, isoleucine and leucine are depicted. On the <i>right side</i> the pathway of medium/short-chain fatty acid oxidation is depicted. BCAT, branched-chain aminotransferase; BCKD complex, branched-chain alpha-keto acid dehydrogenase complex; HIBCH, 3-hydroxyisobutyryl-CoA hydrolase; HIBADH, 3-hydroxyisobutyrate dehydrogenase; HMG-CoA lyase, 3-hydroxy-3-methylglutaryl-CoA lyase; MHBD, 2-methyl-3-hydroxybutyryl-CoA dehydrogenase; MGH, 3-methylglutaconyl-CoA hydratase; IBD, isobutyryl-CoA dehydrogenase; IVD, isovaleryl-CoA dehydrogenase; MCAD, medium-chain acyl-CoA dehydrogenase; MCC, 3-methylcrotonyl-CoA carboxylase; MMSDH, methylmalonate semialdehyde dehydrogenase; SBCAD, short branched-chain acyl-CoA dehydrogenase; SCAD, short-chain acyl-CoA dehydrogenase; SCEH, short-chain enoyl-CoA hydratase; SCHAD, short-chain 3-hydroxyacyl-CoA dehydrogenase</div>
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<p> Fig. 2 </p>
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<div class="figure-caption-contents"><p> Brain MRI of patient 2.… </p></div>
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<p> Fig. 2 </p>
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<div class="figure-caption-contents"><p> Brain MRI of patient 2. FLAIR images of the brain of patient 2… </p></div>
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<div class="figure-caption-contents">Brain MRI of patient 2. FLAIR images of the brain of patient 2 showing multiple periventricular cystic lesions in addition to attenuated signal in the subcortical white matter</div>
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<p> Fig. 3 </p>
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<div class="figure-caption-contents"><p> Brain MRI of patient 4.… </p></div>
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<p> Fig. 3 </p>
</strong>
<div class="figure-caption-contents"><p> Brain MRI of patient 4. Brain MRI of patient 4 showing lesions in… </p></div>
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<figcaption id="figure-caption-2" class="figure-caption-full figure-caption-text" itemtype="http://schema.org/ImageObject" itemprop="description">
<strong class="figure-label">
Fig. 3
</strong>
<div class="figure-caption-contents">Brain MRI of patient 4. Brain MRI of patient 4 showing lesions in the basal ganglia (<b>1</b>) and mesencephalon (<b>2</b>). Bilateral hyperintensities are present in the globi pallidi and the left caudate at the age of 12 months (<b>1a</b>) and display progressive degenerative evolution to atrophy after 1 month (<b>1b</b>) and 6 months (<b>1c</b>) of the disease course. The substantia nigra shows acute lesions at 12 months of age (<b>2a</b>) and evolving into atrophy after 6 months (<b>2b</b>)</div>
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<p> Fig. 4 </p>
</strong>
<div class="figure-caption-contents"><p> SCEH enzyme activity and protein… </p></div>
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<div class="figure-caption-medium figure-caption-text" aria-hidden="true">
<strong class="figure-label">
<p> Fig. 4 </p>
</strong>
<div class="figure-caption-contents"><p> SCEH enzyme activity and protein expression in patients fibroblasts ( <b> a </b> ) SCEH… </p></div>
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Fig. 4
</strong>
<div class="figure-caption-contents">SCEH enzyme activity and protein expression in patients fibroblasts (<b>a</b>) SCEH enzyme activity with crotonyl-CoA as substrate measured in fibroblasts of control subjects (<i>n</i>=10) and fibroblasts of patients 14. Whiskers indicate mean±SD. Patient fibroblasts show a markedly reduced SCEH activity. <b>b</b> Immunoblot analysis with antibodies against SCEH in fibroblasts of two control subjects and fibroblasts of patients 24. The <i>lower</i> panel shows the loading control with antibodies against α-tubulin. Patient fibroblasts show reduced SCEH protein expression</div>
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<p> Fig. 5 </p>
</strong>
<div class="figure-caption-contents"><p> SCEH enzyme activity in patient… </p></div>
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<strong class="figure-label">
<p> Fig. 5 </p>
</strong>
<div class="figure-caption-contents"><p> SCEH enzyme activity in patient fibroblasts measured with different substrates. <b> a </b> Formation of… </p></div>
</div>
<figcaption id="figure-caption-4" class="figure-caption-full figure-caption-text" itemtype="http://schema.org/ImageObject" itemprop="description">
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Fig. 5
</strong>
<div class="figure-caption-contents">SCEH enzyme activity in patient fibroblasts measured with different substrates. <b>a</b> Formation of tiglyl-CoA by incubation of 2-methyl-butyryl-CoA with recombinantly expressed short branched-chain acyl-CoA dehydrogenase (SBCAD) (<i>left panel</i>) and formation of methacrylyl-CoA by incubation of isobutyryl-CoA with isobutyryl-CoA dehydrogenase (IBD) (<i>right panel</i>). After 2 min all substrate is converted into product. <b>b</b> Enoyl-CoA hydratase enzyme activity with tiglyl-CoA (<i>left graph</i>), methacrylyl-CoA (<i>middle graph</i>) and 3-methylcrotonyl-CoA (<i>right graph</i>) in fibroblasts of two control subjects, SCEH deficient patients and a patient with a complete deficiency of mitochondrial trifunctional protein (MTP) and a patient with 3-methylglutaconyl-CoA hydratase (MGH) deficiency. <b>c</b> Enoyl-CoA hydratase enzyme activity with tiglyl-CoA (<i>left graph</i>), methacrylyl-CoA (<i>middle graph</i>) and crotonyl-CoA (<i>right graph</i>) in liver of two control subjects and two SCEH deficient patients (patient 1 and 2). Residual activity in patients samples is indicated in % of mean activity in two control liver samples</div>
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<div class="figure-caption-contents"><p> Pyruvate dehydrogenase subunits in tissue… </p></div>
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<p> Fig. 6 </p>
</strong>
<div class="figure-caption-contents"><p> Pyruvate dehydrogenase subunits in tissue samples. Levels of subunits of pyruvate dehydrogenase are… </p></div>
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Fig. 6
</strong>
<div class="figure-caption-contents">Pyruvate dehydrogenase subunits in tissue samples. Levels of subunits of pyruvate dehydrogenase are shown in liver (<b>a</b>), muscle (<b>b</b>) and fibroblasts (<b>c</b>). Five control samples are shown followed by samples of patients 1 and 2. Decreased levels of the E2 subunit are shown when probed with a pyruvate dehydrogenase antibody cocktail, as well as with an antibody specific to E2 and E3-binding protein. GAPDH, porin and citrate synthase are shown as loading controls</div>
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<p> Fig. 7 </p>
</strong>
<div class="figure-caption-contents"><p> Tiglyl-CoA metabolism. The intersecting enzyme… </p></div>
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<p> Fig. 7 </p>
</strong>
<div class="figure-caption-contents"><p> Tiglyl-CoA metabolism. The intersecting enzyme activities acting upon tiglyl-CoA in liver tissue </p></div>
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Fig. 7
</strong>
<div class="figure-caption-contents">Tiglyl-CoA metabolism. The intersecting enzyme activities acting upon tiglyl-CoA in liver tissue</div>
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<div id="substances" class="substances keywords-section">
<h2 class="title">
Substances
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