Long-chain Acyl coenzyme a dehydrogenase deficiency: An inherited cause of nonketotic hypoglycemia

Three children from unrelated families presented in early childhood with hypoglycemia and cardiorespiratory arrests associated with fasting. Significant hepatomegaly, cardiomegaly, and hypotonia were present at the time of initial presentation. Ketones were not present in the urine at the time of hypoglycemia in any patient; however, dicarboxylic aciduria was documented in one patient at the time of the acute episode and in two patients during fasting studies. Total plasma carnitine concentration was low with an increased esterified carnitine fraction. These findings suggested a defect in mitochondrial fatty acid oxidation, and specific assays were performed for the acyl coenzyme A (CoA) dehydrogenases. These analyses showed that the activity of the long-chain acyl CoA dehydrogenase was less than 10% of control values in fibroblasts, leukocytes, and liver tissue. Activities of the medium-chain, short-chain, and isovaleryl CoA dehydrogenases were not different from control values. With cultured fibroblasts, CO₂ evolution from long-chain fatty acids was significantly reduced, while CO₂ evolution from medium-chain and short-chain fatty acids was comparable to control values—findings consistent with a defect early in the β-oxidation sequence. Studies of acyl CoA dehydrogenase activities in fibroblasts and leukocytes from parents of the patients showed levels of long-chain acyl CoA dehydrogenase activity intermediate between affected and control values and indicated an autosomal recessive form of inheritance of this enzymatic defect. These results describe a previously unrecognized metabolic disorder of fatty acid oxidation due to a deficiency of the long-chain acyl CoA dehydrogenase which may present in early childhood with disastrous consequences. This diagnosis should be considered in children who present with nonketotic hypoglycemia, carnitine insufficiency, and inadequately explained cardiorespiratory arrests.