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Cobalamin C defect: natural history, pathophysiology, and treatment

  • Homocysteine and B-Vitamin Metabolism
  • Published:
Journal of Inherited Metabolic Disease

Abstract

Cobalamin C (Cbl-C) defect is the most common inborn cobalamin metabolism error; it causes impaired conversion of dietary vitamin B12 into its two metabolically active forms, methylcobalamin and adenosylcobalamin. Cbl-C defect causes the accumulation of methylmalonic acid and homocysteine and decreased methionine synthesis. The gene responsible for the Cbl-C defect has been recently identified, and more than 40 mutations have been reported. MMACHC gene is located on chromosome 1p and catalyzes the reductive decyanation of CNCbl. Cbl-C patients present with a heterogeneous clinical picture and, based on their age at onset, can be categorized into two distinct clinical forms. Early-onset patients, presenting symptoms within the first year, show a multisystem disease with severe neurological, ocular, haematological, renal, gastrointestinal, cardiac, and pulmonary manifestations. Late-onset patients present a milder clinical phenotype with acute or slowly progressive neurological symptoms and behavioral disturbances. To improve clinical course and metabolic abnormalities, treatment of Cbl-C defect usually consists of a combined approach that utilizes vitamin B12 to increase intracellular cobalamin and to maximize deficient enzyme activities, betaine to provide a substrate for the conversion of homocysteine into methionine through betaine-homocysteine methyltransferase, and folic acid to enhance remethylation pathway. No proven efficacy has been demonstrated for carnitine and dietary protein restriction. Despite these measures, the long-term follow-up is unsatisfactory especially in patients with early onset, with frequent progression of neurological and ocular impairment. The unfavorable outcome suggests that better understanding of the pathophysiology of the disease is needed to improve treatment protocols and to develop new therapeutic approaches.

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Abbreviations

AdoCbl:

Adenosylcobalamin

BHMT:

Betaine-homocysteine methyltransferase

Cbl:

Cobalamin

CBS:

Cystathionine beta synthase

HUS:

Hemolytic uremic syndrome

MeCbl:

Methylcobalamin

MMA:

Methylmalonic acid

MTHFR:

Methyl tetrahydrofolate reductase

OH-Cbl:

Hydroxycobalamin

SAM:

S-adenosylmethionine

SAH:

S-adenosylhomocysteine

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Authors and Affiliations

  1. Division of Metabolism, Bambino Gesù Children’s Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy

    Diego Martinelli, Federica Deodato & Carlo Dionisi-Vici

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  1. Diego Martinelli
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  2. Federica Deodato
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  3. Carlo Dionisi-Vici
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Correspondence to Carlo Dionisi-Vici.

Additional information

Communicated by: Brian Fowler

References to electronic databases: Methylmalonic aciduria and homocystinuria cbl-C type: OMIM #277400

MMACHC gene: OMIM *609831

Competing interest: None declared.

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Martinelli, D., Deodato, F. & Dionisi-Vici, C. Cobalamin C defect: natural history, pathophysiology, and treatment. J Inherit Metab Dis 34, 127–135 (2011). https://doi.org/10.1007/s10545-010-9161-z

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