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ExtractA male sibling who was born of healthy parents and who died at the age of five days with the clinical picture of severe hypotonia, arefiexia, hyperventilation, and grunting is described. An older female sibling with identical symptoms had died some years previously. The parents were unrelated and had three other healthy children. The patient exhibited severe metabolic acidosis which was resistant to therapy. This acidosis was caused by the presence in blood of propionic acid in a very high concentration (5.4 mM/1). The high levels of urea and potassium also present were probably the result of a markedly reduced urine production caused by dehydration. The levels of amino acid in plasma revealed low values for one amino acid, normal values for other amino acids, and high values for lysine, histidine, valine, isoleucine, and leucine.At autopsy, except for a right descending aortic arch, no gross anomalies were found, although the liver was enlarged, probably because of increased fat content. Microscopic examination showed a fatty degeneration of liver cells, degeneration of the Purkinje cells and the granular layer in the cerebellum, and macrophages containing debris of blood cells in the bone marrow and in the spleen. Gas chromatography was used to determine the nature of the accumulated fat in the liver. Among the normal constituents of liver triglycerides, three abnormal fractions were observed, two of which contained G 15 and G 17 straight chain fatty acids. These were not observed in normal liver fat. The combination of propionicacidemia and the storage of fatty acids with an uneven chain number in the liver pointed to a block in the conversion of propionic acid into methylmalonic acid. Speculation-

Hyperornithinaemia due to a transport of ornithine across the inner mitochondrial membrane was demonstrated in three patients by measuring ornithine uptake by fibroblast mitochondria. Particulate compartments and soluble cytoplasm of fibroblasts were separated by a slight modification of the digitonin method of Zuurendonk and Tager. Patients' fibroblast pellet fraction contained significantly less radioactivity than control fibroblast pellet fraction after incubation of fibroblasts with [14C]-ornithine. Since neither of the patients was deficient in ornithine-delta-oxoacid aminotransferase, we concluded that in these hyperornithinaemia patients a defect exists for transport of ornithine across the inner mitochondrial membrane. The exact nature of this transport defect remains to be elucidated.

Propionic acidemia usually presents in the newborn period with severe metabolic acidosis and lethargy. A 31-year-old man with adult onset chorea and dementia had propionic acidemia due to propionyl CoA carboxylase deficiency. Metabolic investigations may prove useful in patients with movement disorder of unknown etiology.

Two children are described who suffered from hypoglycemia and liver impairment. Assays of gluconeogenic enzymes in liver samples taken immediately after death demonstrated a deficiency of phosphoenolpyruvate carboxykinase, a key enzyme of gluconeogenesis. Post mortem examination demonstrated massive fat deposition in liver and kidney and to a lesser extent in other tissues. The fatty changes in liver and kidney could be explained by the absence of phosphoenolpyruvate carboxykinase, which would cause an alteration in the mitochondrial-cytosolic processes related to gluconeogenesis.

A 25-year-old woman with Kearns-Sayre syndrome (KSS) had complete external ophthalmoplegia, short stature, ataxia, cardiac conduction defects, and pigmentary retinopathy. Muscle biopsy revealed ragged-red fibers. Electron microscopy showed increased numbers of mitochondria with disordered structure and paracrystalline inclusions. Enzymatic analysis revealed a deficiency of complex II of the mitochondrial respiratory chain, and, more specifically, a deficiency of succinic dehydrogenase, although both subunits of this enzyme proved to be present by immunologic analysis. Therapy with vitamin cofactors did not result in short-term improvement. This appears to be the first report of complex II deficiency in a patient with KSS.

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