J. - Pediatrics · via the intermediate formation of phenyl-The enzyme that catalyzes reaction (3) ... ion-reactive substances of the blood, phe-nylalanine administration did not

PHENYLPYRUVIC OLIGOPHRENIA

By Alton Meister, M.D.

Department of Biochemistry, Tufts University School of Medicine

Phenylalanine

AMERICAN ACADEMY OF PEDIATRICS - PROCEEDINGS 1021

ADDRESS: 136 Harrison Avenue, Boston 11, Massachusetts.

3. Beutler, E., Robson, M. J., and Butten-wieser, E. : The gbutathione instability ofdrug-sensitive red cells. J. Lab. & Gun.Med., 49:84, 1957.

4. Zinkham, W. H., and Childs, B. : The effectof vitamin K and naphthabene metabolites

on glutathione metabolism of erythro-

cytes from normal newborns and patientswith naphthalene hemolytic anemia (ab-stract). A.M.A. J. Dis. Child., 94:420,1957.

5. Childs, B., Zinkham, W. H., Browne, E. A.,

P HENYLPYIIUVIC OLIGOPH1IENIA is an in-herited disease characterized by mental

deficiency and urinary excretion of phenyl-

pyruvic acid.#{176} Patients with this disorder

are unable to carry out a particular enzy-

matic step in the metabolism of phenylab-

anine; this reaction is the conversion of

phenylalanine to tyrosine:

Kimbro, E. L., and Torbert, J. V. : Agenetic study of a defect ill glutathione

metabolism of the erythrocytc. Bull. JohnsHopkins Hosp., 102:21, 1958.

6. Carson, P. E., Flanagan, C. L., Ickes, C. E.,alld Alving, A. S. : Enzymatic deficiency

ill primaquine-sensitive er�throcy’tes. Sci-

ence, 124:484, 1956.7. Stanbury, J. B., and Querido, A. : Genetic

and environmental factors in cretinism:

A classification. J. Gun. Endocrinol., 16:1522, 1956.

trait; it has been estimated that the gene

is carried by approximately 0.5 to 1% of the

population. Although most patients with

this disease exhibit markedly reduced men-

tal capacity, a few show only moderate

retardation. A high percentage of patients

with phenylketonuria have fair skin, blue

eyes and blond hair. About 25% of patients

()-Cl12__CIIC()(�)1I + l;�� 02 � HO()-_CII2-dH-C�1)OH

NH2 NH,

These individuals therefore appear to be

human mutants, analogous to mutants such

as those which have been induced in Neu-

rospora crassa and Escherichia coli. How-

ever, in contrast to the enzymatic defect in

certain mutant microorganisms, which is of-

ten recognizable in terms of a specific

tritional requirement, the metabolic block

in phenylpyruvic oligophrenia is associated

with a relatively complex picture.

Phenyipyruvic oligophrenia is a recessive

0 Phenybpyruvic oligophrenia (phenylketonuria)

was first described by F#{248}lbingin 1934.’ Since this

time, more than 300 cases have been reported in

the literature. Reviews have appeared describing

the 23 genetic 23 physicaland mental findings,2� and pathologic studies.2

‘Fyrosit�e

with phenylpyruvic obigophrenia have cx-

perienced seizures, and many of these pa-

tients have been reported to show abnormal

electroencephalograms. Several necropsies

have revealed evidence of abnormal mycli-

nation; on the other hand, other post-

mortem studies have been described as es-

sentially negative.

Patients with phenylpyruvic oiigophrenia

may excrete as much as 1 to 2 grn each of

phenylpyruvic acid2,68 and phenyilactic

9� io per day; these compounds are not

usually detectable in normal urine (Fig. 1).

Urinary excretion of phenylalanine, nor-

maliy no more than about 30 mg/day, may

be as high as 1 gm/day in phenylpyruvic

oligophrenia.2 6, Ii Phenylacetylgiutamine,

by guest on June 26, 2021www.aappublications.org/newsDownloaded from

1022 CONGENITAL METABOLIC DISEASE

which is present in normal urine (about

300 mg/day), may be excreted in considera-

ble quantities (about 1 to 3 gm12-14).

Phenylalanine accumulates in the blood;

concentrations of 10 to 60 mg/100 ml of

blood plasma have been observed (normal

range 1 to 3 gm2 15) High concentrations of

phenylalanine have also been observed in

the spinal fluid. In contrast, relatively little

phenylpyruvic acid, phenyllactic acid and

phenybacetic acid have been detected in the

blood of patients with phenylpyruvic obigo-

phrenia.2 16 Studies on one newborn with

phenylketonuria have been reported; the

phenylalanine content of the umbilical cord

blood was normal, and the concentration of

phenylalanine in the serum rose to abnor-

ma! levels within a few days after birth.

This infant did not excrete a detectable

quantity of phenylpyruvic acid until 34

acetic acid. The enzymatic coupling of phe-

nylacetic acid and gbutamine (reaction 9,

Fig. 2) is unique in that this reaction takes

place only in human tissues (and possibly

those of the chimpanzee).’921 In the mon-

key, dog, rat, rabbit and other lower forms,

phenylacetic acid is coupled with glycine

to form phenylacetylglycinc (phenybace-

tune acid). It would therefore appear that

the metabolic pathways of phenylalanine

and of glutamine in man are unique in tilis

respect as compared with most of the other

mammals.

Information is now available concerning

the enzyme system responsible for phenyl-

acetylgiutamine formation in human kidney

and 2223 The evidence suggests that

phenybacetyl-adenylate (phenylacetyl-AMP)

and phenylacetyl-coenzyme A (phenylace-

tyl-CoA) are intermediates in this process: #{176}

(1) Phenylacetate + AlT -+ Phenylacetyl-AMP + PP(2) Phenylacetyl-AMP + CoA-SH -+ Phenylacetyl-CoA + AMP

(3) Phenylacetyl-CoA + Glutamine ---� Phenylacetylglutamine + CoA-SH

days after birth.’7

In considering the biochemical phe-

nomena associated with phenylpyruvic oIl-

gophrenia, it is desirable to review briefly

the present status of knowledge concerning

the intermediary metabolism of phenylal-

anine and tyrosine. A scheme summarizing

some of this information is given in Fig-

ure 2. The available evidence (derived to

a considerable extent from studies on other

mammals) indicates that the major quanti-

tative pathway of phenybalanine degrada-

tion is conversion to tyrosine. Tyrosine is

subsequently converted by transamination

to p-hydroxyphenyipyruvic acid, which is

oxidized to homogentisic acid, which in

turn is oxidized to fumaric and acetoacetic

acids.

An alternative pathway of phenylalanine

metabolism involves transamination to phe-

nylpyruvic acid; further metabolism of this

�-keto acid yields phenyllactic acid and

phenylacetylglutamine, the latter probably

via the intermediate formation of phenyl-

The enzyme that catalyzes reaction (3)

has been purified from human liver and

kidney and appears to be present only in

human tissues.’4 As will be discussed below,

the conversion of phenylalanine to phenyb-

pyruvic acid and of the latter compound to

phenybbactate and phenybacetylgiutamine,

normally of minor quantitative significance,

become the major degradative pathways of

phenylalanine metabobism in phenylpyru-

vie oligophrenia.t The reduction of phenyl-

pyruvate to phenyllactate may be catalyzed

0 Abbreviations : ATP, adenosine triphosphate;

AMP, adenybic acid; PP, pyrophosphate; CoA-S11

and CoA, coenzyme A.

I A preparation of liver obtained by biopsy from

a patient with phenylketonuria was found to formphenylacetyiglutamine at approximately five times

the rate observed with liver preparations obtainedfrom patients without phenylketonuria.�’ It wouldappear that this enzyme system is more active inindividuals with phenybketonuria and may possibly

be adaptive in nature; however, final conclusionsmust await studies on additional samples of phenyl-ketonuric liver.


N MelaninPhenylalanine

12Phen�lpyruvate

�1’ PhenyilactatePhenviacetate

‘E- Glutamine

9

Phenvlacet�lglutam inc

j)- Hvdroxvphenvlpvruvate

Homogentisate

Fu marylacetoacetate

16


Fic. 2. Scheme of the metabolism of phenylalanine and tyrosine (adapted from Meister’�).

) Norepinephrine-.-..---.--� � Eprnephrine

� � Di-iodotyrosine

.3 ThyroxineTri-iodothyronine

Fumarate -I- Acctoacetate


0(1)

U


L..* p m mm p.m p,,iFIG. 3. Conversion of C-14 L-phenylalanine to C-14

tyrosine catalyzed by a preparation of phenyl-ketonuric liver (P) in the absence and presence of

purified protein fractions (I and II) isolated fromrat liver.’0 (This patient was made available for

study by Dr. Marshall Kriedberg of the Boston

Floating Hospital.)

in the isolated tyrosine.’8 Since a smallamount of radioactive tyrosine was formed,

it is possible that the block may not be

complete, or that some conversion of phe-

nylalanine to tyrosine is carried out by the

bacterial flora.

Study of liver specimens obtained from

patients with phenylketonuria at necropsy

or operation failed to reveal evidence of

any enzymatic activity capable of convert-

ing phenyialanine to tyrosine, whereas liver

specimens obtained from individuals with

other conditions catalyzed the conversion

of phenylabanine to �

The mechanism of the enzymatic conver-

sion of phenylalanine to tyrosine is not as

yet completely understood. However, it has

been found that the reaction, which ap-

parentby takes place exclusively in the liver,

requires the participation of diphosphopyri-

dine nucleotide or triphosphopyridine nu-

cleotide and oxygen.31’3 The enzyme sys-

tem can be separated into two fractions :32

One of these (Fraction I) is relatively labile

and is found solely in the liver, while the

other (Fraction II) is more stable, and is

found in certain other tissues as well. A lack

of either Fraction I or Fraction II (or of both

fractions) could be responsible for the

marked decrease in the conversion of phen-

ylalanine to tyrosine in phenylpyruvic oiig-

ophrenia. If patients with phenylketonuria

were unable to synthesize Fraction II, then

one might expect abnormal metabolic func-

tion in a number of tissues (perhaps includ-

ing the brain). On the other hand, a (lefi-

ciency of Fraction I would represent a spe-

cific hepatic defect.

In an attempt to shed ligblt 011 this pro1�-

1cm, a study of the conversion of phenylala-

nine to tyrosine in phenylpyruvic oligo-

phrenia was undertaken in the author’s

laboratory.3#{176} An enzyme preparation oh-

tamed from liver obtained by biopsy from

a patient with phenylpyruvic obigophrenia

did not catalyze detectable conversion of

phenylabanine to tyrosine. However, when

a purified preparation of Fraction I ob-

tamed by fractionation of rat liver was

added to the phenylketonuric-liver prepara-

tion, a very considerable conversion of

phenylalanine to tyrosine was observed

(Fig. 3). An analogous experiment in which

Fraction II (also prepared from rat liver)

was added to the phenylketonuric-liver

preparation was also carried out; in this

case only a small conversion of phenylala-

nine to tyrosine was observed. This rela-

tively small effect was consistent with the

fact that neither of the purified fractions

was completely free of the other. The strik-

ing activation of the conversion of phen-

ylabanine to tyrosine produced by addi-

tion of rat Fraction I to the phenylketo-

nuric-liver preparation represents strong

evidence for the absence of Fraction I in

the phenylkctonuric liver.

In these experiments, it was not feasible

to separate the small quantity of liver re-

moved at operation into fractions corre-

sponding to Fractions I and II. In mdc-

pendent studies by Mitoma et al.,34 liver

specimens obtained from patients with

phenylketonuria at necropsy were frac-

tionated in this manner. The presence of ac-

tivity corresponding to Fraction II was dem-

onstrated in the necropsy liver specimens.

Unfortunately, Fraction I could not be

demonstrated in liver obtained from mdi-

viduals either with or �vithoiit phenylketo-

nuria; presumably, Fraction I, was macti-

vated soon after death.

Nevertheless, demonstration of Frac-



tion II activity in the liver of patients with

phenylketonuria is consistent with the con-

elusion that the metabolic defect in phenyb-

pyruvic oligophrenia is associated with a

deficiency of Fraction I. The defect there-

fore appears to be primarily one of the

specific hepatic function rather than one

which might be expected to manifest itself

in a number of tissues. It should be empha-

sized that studies thus far have dealt only

with enzyme activity. The available data

do not answer the question as to whether

the enzyme is absent, or whether it is pres-

ent in an inactive state.

It is not immediately clear as to how a

deficiency in the conversion of phenylala-

nine to tyrosine may be rebated to the cx-

traordmnary degree of mental retardation

associated with this disease. � It does not

seem likely that individuals with phenylke-

tonuria suffer from a marked deficiency of

tyrosine since this amino acid is probably

available in sufficient quantities in the diet.

Furthermore, tyrosine suppiemen tation of

the diet does not ameliorate the condition.’

However, tyrosine must be considered a

dietary essential amino acid for patients

with phenylketonuria, although this has not

yet been rigorously demonstrated in cx-

periments of the type performed by Rose.35

It is conceivable, of course, that the cere-

bra! lesion and the hepatic abnormality are

separate phenomena not causally related.

However, there is evidence consistent with

the belief that these defects are related.

Studies on microorganisms have provided

much support for the “one gene-one en-

zyme” concept;36 the development of phe-

nomena secondary to a block is not un-

common in mutant microorganisms.

A relationship between the enzymatic

defect in the liver and the cerebral lesion

may become understandable in terms of the

consequences of the accumulation of phen-

* It is of interest to note that alcaptonuria, a

condition associated with a major l)lOck in tyrosine

metabolism (deficiency of homogentisic acid oxida-

tion, reaction 5, Fig. 2), is not accompanied by

serious systemic or cerebral complications.

ylalanmne. That such accumulation oc-

curs is evident from the high concentrations

of phenylalanine in the blood, and the in-

creased urinary excretion of this amino

acid. An obvious consequence of phenybala-

nine accumulation is increased formation of

phenyipyruvic acid. An increased concen-

tration of phenylalanine would be expected

to drive reaction 2 (Fig. 2) in the direction

of phenylpyruvic acid formation, and more

of this a-keto acid would therefore be

available for conversion to phenylacetic

acid, phenyblactic acid and phenylacetyl-

giutammne. The conversion of tyrosine to

p-hydroxyphenyipyruvic acid (reaction 3.

Fig. 2) takes place by transamination,3739

and it is probable that the conversion of

phenylalanmne to phenylpyruvate proceeds

by a similar mechanism.

Since these transamination reactions are

reversible, it would be expected that less

phenylpyruvic acid might be formed in the

presence of increased concentrations of

amino � Thus, a reduction in the

excretion of phenylpyruvic acid and phenyl-

lactic acid by patients with phenyiketonuria

was observed following relatively large oral

doses of certain amino acids.’� For example,

a significant reduction of phenylpyruvic

acid excretion was observed in an 18-kilo-

gram girl with phenyiketonuria 1 hour after

administration of 136 miliimoles of L-giuta-

mine; a minimum excretion of about 40% of

the control value was reached 4 hours after

administration of giutamine, and the excre-

tion of keto acid returned to the control

bevel after 6 hours. A considerable increase

in the excretion of cz-ketogbutarate was oh-

served during the period of reduced phen-

Similar findings were observed in two

patients with phenylketonuria after ad-

ministration of L-glutamate and L-aspara-

gine; however, administration of sodium

succinate, glycine or D-glucose had no ef-

feet on phenybpyruvic acid excretion. It is

of interest that the excretion of phenyl-

acetylglutammne was unchanged by the ad-

ministration of glutammne; the decrease in

phenylpyruvic acid formation may not have



been great enough to affect the formation

of phenylacetylglutamine.

Since administration of glutamine did

not increase phenylacetylgbutamine excre-

tion, it appears unlikely that there is a de-

ficiency of glutamine for the coupling re-

action, and there is no reason to believe

that the excretion of phenylacetylglutamine

by patients with phenylketonuria represents

a serious loss of glutammne from the body.

The results of these studies on the effects

of administration of amino acids in phenyl-

pyruvic oligophrenia are consistent with

the belief that the conversion of phenylal-

anine to phenylpyruvic acid is a transamina-

tion reaction. The possible therapeutic ef-

fectiveness of amino acid administration

requires further study and consideration.

Formation of products of phenylalanmne

metabolism (e.g., phenylpyruvic acid and

phenyllactic acid) may be reduced by such

amino acid administration; however, a

greater accumulation of phenylalanmne

would also be expected to occur.

Although it is plausible that the mental

defect in phenylpyruvic oligophrenia is a

consequence of high concentrations of phen-

ylalanine or of metabolites of this amino

acid, the mechanism of such an effect is at

present obscure. Evidence in favor of this

hypothesis arises from studies in which

patients with phenylketonuria have been

administered diets containing very low

levels of phenylalanine.4246 Improvement

has been reported in some patients. The

effects of dietary phenylalanine restriction

on the urinary excretion of phenylpyruvic

acid and on the concentration of phenylala-

nine in the blood are dramatic; the excre-

tion of phenylpyruvic acid may decrease to

virtually zero and the phenylabanine in the

blood may approach normal concentrations.

It has also been reported that patients who

previously experienced seizures have cx-

hibited less tendency to have such attacks

when given a low phenylalanine diet. In

some cases, the electroencephabographic

findings appeared to become more normal.

The improvement observed in patients

receiving the restricted phenylalanine diet

is consistent with the hypothesis that high

blood and tissue concentrations of phen-

ylalanmne or products of phenylaianmne me-

tabobism may be responsible for the cerebral

defect. Thus, high concentrations of phenyl-

alanine, phenylpyruvic acid, phenyllactic

acid or phenylacetic acid, for example,

might produce cerebral damage or prevent

normal cerebral development at a crucial

stage.

The possible toxicity of phenylacetic acid

has been considered by several investiga-

tors.4749 Other compounds have been re-

ported to be excreted in greater than nor-

mal quantities in phenylketonuria;49’2

these include o-hydroxyphenylacetic acid,

p-hydroxyphenylacetic acid, p-hydroxyphe-

nyllactic acid, indoleacetic acid and indole-

lactic acid. The presence of relatively barge

amounts of these products may represent

abnormalities in the metabolism of tyro-

sine and tryptophan, due to inhibition by

high concentrations of phenylalanine or

phenylpyruvic acid, or may possibly be

caused by an adaptive increase of the en-

zyme systems concerned with the conver-

sion of phenylabanmne to phenylpyruvate,

phenyblactate and phenylacetyiglutammne.

An increase in transaminase activity, for

example, might result in a greater conver-

sion of tryptophan and tyrosine to their

respective �-keto acid analogues, which in

turn, could be reduced or decarboxylated

(Fig. 3).

The presence of o-hydroxyphenyiacetic

acid in the urine of patients with phenyl-

pyruvic oligophrenia is somewhat surpris-

ing since o-tyrosine is not known to be a

natural metabolite. o-Hydroxyphenylacetic

acid has been shown by isotopic studies to

0 A preparation of liver obtained by biopsy from

a patient with phenybketonuria was found to form

phenybacetybgbutamine at approximately five times

the rate observed with liver preparations obtainedfrom patients without phenylketonuria.’� It wouldappear that this enzyme system is more active inindividuals with phenylketonuria and may possibly

be adaptive in nature; however, final conclusions

must await studies on additional samples of phenyl-

ketonuric liver.



\/\\/ NH

/ � Tryptophan

\�)N

H Indolepyruvic Acid

N

H Indoleacetic Acid

K�l�H2__C00hT

�/\/ OHN

H Indolelactic Acid

arise from phenylalanine;53 the mechanism

of its formation is not yet known. It is of

considerable interest that the excretion of

these compounds has been reported to de-

crease when patients with phenylketonuria

follow a phenylalanine-restricted regi-

men.45

It is possible that high concentrations of

phenylalanine in blood and tissue result in

an amino-acid imbalance which interferes

with the metabolism of other amino acids

(especially tyrosine) and perhaps also with

protein synthesis. High concentrations of

phenylalanine have been found to inhibit

mushroom tyrosinase competitively,5� and

similar findings have been made with mam-

mabian tyrosinase;5’ these observations sug-

gest a mechanism for the toxicity of phen-

ylalanmne. It may be observed, in this con-

nection, that some patients with phenylke-

tonuria have shown an increase in pigmen-

tation of skin and hair after receiving a bow-

phenylalanmne diet for several months.

There are now many examples of experi-

mentally induced amino-acid imbalance,

and it is evident that a naturally occurring

amino acid, if present in sufficient concen-

tration, may act as an amino-acid antago-

nist. Both phenylalanmne and phenylpyruvic

HO(��CH2-CH-COOH

NH,

Tyrosine

HO()-CH2_C_COOH

p-Hydroxyphenylpyruvic Acid

(HO()-C112-COOH

p-Ilydroxyphenylacetic Acid

�

� p-Hydroxyphenyllactic Acid

acid have recently been found to interfere

with metabolism of tyrosine in in-vitro

studies.56 High concentrations of phenylala-

nine might also affect formation of thyroid

hormone or of epinepkrine and norepine-

phrine.57 It has recently been shown that

certain amino-acid antagonists are incorpo-

rated into proteins in place of their natur-

ally occurring analogues.58�#{176} Phenylalanine

may inhibit synthesis of certain proteins

(perhaps as a tyrosine or tryptophan an-tagonist), or, in the presence of high con-

centrations of phenylalanine, abnormal pro-

teins containing large amounts of this

amino acid may be formed. Although

studies on the phenylalanine content of

proteins from patients with phenylketo-

nuria have been carried 662 further

work would be desirable. It is of interest

that serum obtained from some patients

with phenylketonuria has been reported

to contain abnormal 13-globulins; these dis-

appear when the patients are placed on

restricted phenylalanine diets.63

Although several plausible mechanisms

for the toxic effect of phenylalanmne may

be formulated (Fig. 4), a complete bio-

chemical explanation of the cerebral defect

is still lacking. The current procedure of


Protein

Melanin

Thyroid hormone

Epinephrine and

norepincphrine

CO� + H3O + Urea


INHIBITORY EFFECTS

IMETABOLISM OF OTHER AMINO ACIDS

EIITYROSINE�J-

/ ACTION OF “ADAPTIVELY” INCREASED ENZYMES

[OTHER AMINO ACIDS

\ TOXIC METABOLITES i-,

/

Fic. 4. Some possible consequences of phenylabanine accumulation.

giving patients with phenylketonuria a re-

stricted dietary intake of phenylalanine is

a rational therapy and has apparently been

at least partly successful.

Greater success may attend studies on

very young infants; if this is the case, the

importance of early diagnosis becomes ob-

vious.#{176}It remains to be demonstrated that

normal cerebral development can be

achieved by instituting a restricted phenyl-

alanine diet from birth in affected individ-

uals. Until this is accomplished, the possi-

bility that abnormalities exist other than

those directly related to phenylalanine ac-

cumulation cannot be conclusively cx-

0 J� has recently been reported that parents of

patients with phenylketonuria exhibit prolonged

high concentrations of phenybabanine in the bbood

after oral test doses of this amino acid.’4 Theseindividuals exhibit none of the signs or symptoms

of phenylpyruvic obigophrenia. This important find-

ing may bead to the development of a procedurefor the detection of heterozygous individuals, andit provides additional evidence for the hypothesis

that the primary lesion in phenylketonuria is adisturbance of the conversion of phenylalanine to

tyrosine.�

eluded. It must also be noted that it is not

yet certain that the mental defect is irre-

versibbe in older patients.

Although some improvement has been

observed with the low phenylalanine regi-

men, other approaches should probably not

be abandoned. It is possible that ways can

be found to promote the detoxification and

the excretion of phenybaianmne and its

metabolites. The possibility of producing

a bacterial flora in the intestine capable of

converting phenylalanmne to tyrosine, al-

though perhaps difficult to achieve, de-

serves at least brief mention. However, it

will be of utmost importance to pursue ac-

tively research on the enzyme system that

catalyzes the para-hydroxylation of phenyl-

abanine, and to determine ultimately the

exact nature of the genetic and molecular

defects in phenylpyruvic oligophrenia. It

will be necessary to learn whether the en-

zyme is absent or whether it is present in

an inactive form. Such information will be

essential for the development of therapy

based on enzyme replacement or enzyme

activation. This type of information, as well



as data on the pathogenesis of the cerebral

lesion, will be of importance not only in

terms of this disorder, but may well be sig-

nificant for the understanding of other dis-

ease phenomena.

ACKNOWLEDGMENT

The author acknowledges the generous

support of the National Science Founda-

tion and the National Institutes of Health,

Public Health Service in some of tile in-

vestigations described in this report.

REFERENCES

1. F�lling, A. : Uber Ausscheidung von

Phenylbrenztraubens#{228}ure in den Ham

abs Stoffwechselanomabie in Verbindung

mit Imbezillit#{228}t. Ztschr. physiol. Chem.,

227: 169, 1934.

2. Jervis, C. A. : Phenylpyruvic oiigophrenia(phenylketonuria). A. Res. Nerv. &

Ment. Dis., Proc., 33:259, 1954.3. Cowie, V. : Phenylpyruvic obigophmenia.

J. Ment. Sc., 97:505, 1951.4. Paine, R. S.: Tile variability in mani-

festations of untreated patients withphenylketonuria (phenylpymuvic acid-

uria). PEDIAi’iucs, 20:290, 1957.5. Mautner, H., and Quinn, K. V. : Phenyl-

pyruvic oligophrenia. Ann. paediat.,172:1, 1949.

6. Dann, M., Mamples, E., and Levine, S. Z.:Phenybpymuvic oligophrenia. Report of

a case in an infant with quantitativechemical studies of the urine. J. Clin.Invest., 22:87, 1943.

7. Penrose, L., and Quastel, J. H. : Metabolicstudies in phenylketonuria. Biochem. J.,31:266, 1937.

8. Berry, J. P., and Woolf, L. I. : Estimationof phenylpyruvic acid. Nature, 169:202,

1952.

9. Zelber, E. A. : Isolierung von Phenyl-milchs#{228}ure und Phenybbreuztrauben-

s#{228}ureaus Ham bei Imbecillitas phenyi-pyruvica. Helvet. chim. acta, 26:1614,

1943.10. Jervis, C. A. : Excretion of phenvlalanine

and derivatives in phenylpyruvic oligo-phrenia. Proc. Soc. Exper. Biol. & Mcd.,

75:83, 1950.

11. Borek, E., Brecher, A., Jcrvis, C. A., and

Waelsch, H. : Oligophrenia phenvl-

pyruvica. II. Constancy of the meta-bobic error. Proc. Soc. Exper. Biol. &

Med., 75:86, 1950.

12. Woolf, L. I. : Excretion of conjugatedphenybacetic acid in phenylketonuria

(abstract). Biochem. J., 49:ix, 1951.13. Stein, W. H., Pabadini, A. C., Hirs,

C. H. W., and Moore, S. : Phenylacetyl-glutamine as a constituent of normal

human urine (Communication to the

editor). J. Am. Chem. Soc., 76:2848,1954.

14. Mcister, A., Udenfriend, S., and Bessman,S. P. : Diminished phenylketonuria inphenylpymuvic oligophmcnia after ad-

ministration of L-glutamine, L-gbuta-

mate or L-asparagine. J. Cbin. Invest.,35:619, 1956.

15. Jervis, C. A., Block, R. J., Boiling, D., andKanze, E. : Chemical and metabolicstudies on phenylalanine. II. The phenyl-abanine content of the blood and spinalfluid in phenyipyruvic oiigophrenia. J.Biob. Chem., 134:105, 1940.

16. Jervis, G. A. : Studies on phenyipyruvic

oligophrenia. Phenyipymuvic acid con-tent of blood. Proc. Soc. Exper. Biol.& Med., 81:715, 1952.

17. Armstrong, M. D., and Binkley, E. L., Jr.:

Studies on phenybketonuria. V. Observa-

tions on a newborn infant with phenyb-ketonuria. Proc. Soc. Exper. Biol. &

Med., 93:418, 1956.18. Mcister, A. : Biochemistry of the Amino

Acids. New York, Acad. Press, 1957,p. 358.

19. Thierfelder, H., and Sherwin, C. P.Phenylacetybglutamin, em Stoffwechscl-

Produkt des menschlichen Korpers nachEingabe von Phenyl-essigsaure. Bcr.

deutsch. chem. Gesellsch., 47:2630,

1914.20. Sherwin, C. P. : Comparative metabolism

of certain aromatic acids. J. Biol. Chcm.,31:307, 1917.

21. Sherwin, C. P., Woff, M., and Wolf, W.:

The maximum production of glutamineby the human body as measured by the

output of phenylacetylglutamine. J.Biol. Chem., 37:113, 1919.

22. Moldave, K., and Meister, A. : Enzymicacylation of gbutamine by phenvlacetic

acid. Biochim. et bioph�s. aeta, 24:654,

1957.

23. Moldave, K., and Meister, A. : Participa-tion of phenylacetyl-adenylate in the

enzymic synthesis of phenyiacetybgluta-

mine. Biochim. et biophys. acta, 25:434,

1957.24. Mobdave, K., and Meister, A. : Synthesis

of phenylacetylgiutammne by human tis-sues. J. Blob. Chem., 229:463, 1957.



25. Moldave, K., and Meister, A. : Unpub-lished data.

26. Meister, A. : Reduction of a, -,�‘-diketo anda-keto acids catalyzed by muscle prepa-rations and by crystalline lactic dehy-drogenase. J. Blob. Chem., 184:117,1950.

27. Jervis, G. A. . Studies on phenylpyruvic

oligophrenia. The position of the meta-bolic error. J. Biol. Chem., 169:651,1947.

28. Udenfriend, S., and Bessman, S. P. : Thehydroxyiation of phenybalanine and anti-

pyrine in phenylpyruvic oligophrenia.J. Biol. Chem., 203:961, 1953.

29. Jervis, G. A. : Phenylpyruvic oligophreniadeficiency of phenylalanmne-oxidizing

system. Proc. Soc. Exper. Blob. & Med.,82:514, 1953.

30. Wallace, H. W., Mobdave, K., and Meister,A. : Studies on conversion of phenyla-lanine to tyrosine in phenylpyruvic oligo-phrenia. Proc. Soc. Exper. Biob. & Med.,94:632, 1957.

31. Udenfriend, S., and Cooper, J. R. : Theenzymatic conversion of phenylalanineto tyrosine. J. Biol. Chem., 194:503,1952.

32. Mitoma, C. : Studies on partially purifiedphenylalanine hydroxylase. Arch. Bio-chem., 60:476, 1956.

33. Kaufman, S. : The enzymatic conversion ofphenylalanine to tyrosine. J. Biol. Chem.,226:511, 1957.

34. Mitoma, C., Auld, R. M., and Udenfriend,S. : On the nature of enzymatic defectin phenylpymuvic oligophrenia. Proc.Soc. Exper. Biob. & Med., 94:634, 1957.

35. Rose, W. C. : Amino acid requirements ofman. Fed. Proc., 8:546, 1949.

36. Beadle, G. W. : Biochemical genetics.Chem. Rev., 37:15, 1945.

37. La Du, B. N., Jr., and Greenberg, D. M.:The tyrosine oxidation system of liver.I. Extracts of rat liver acetone powder.1. Biol. Chem., 190:245, 1951.

38. Schepartz, B. : Transamination as a step

in tyrosine metabolism. J. Biol. Chem.,193:293, 1951.

39. Knox, W.E., and Le May-Knox, M. : Theoxidation in liver of l-tyrosine to aceto-acetate through p-hydroxyphenyipyru-vate and homogentisic acid. Biochem.J.,49:686, 1951.

40. Meister, A., and Tice, S. V. : Transamina-tion from glutammne to a-keto acids.J. Biob. Chem., 187:173, 1950.

41. Meister, A. : Transamination. AdvancesEnzymol., 16:185, 1955.

42. Bickel, H., Gerrard, J., and Hickmans,E. M. : Influence of phenybabanine intakeon phenyiketonuria. Lancet, 2:812,1953.

43. Bickel, H., Cerrard, J., and Hickmans,E. M. : The influence of phenybabanineintake on the chemistry and behaviourof a phenybketonuric child. Acta paediat.,43:64, 1954.

44. Woolf, L. I., Griffiths, R., and Moncrieff,A. : Treatment of phenylketonuria witha diet low in phenybabanine. Brit. M. J.,1:57, 1955.

45. Armstrong, M. D., and Tyler, F. H.:Studies on phenybketonuria. I. Restrictedphenylalanine intake in phcnylketonuria.J. Clin. Invest., 34:565, 1955.

46. Homer, F. A., and Streamer, C. W. : Effectof phenybalanine-restricted diet on pa-tients with phenybketonuria. J.A.M.A.,161:1628, 1956.

47. Woolf, L. I., and Vulliamy, D. G. : Phenyl-ketonuria with a study of the effect uponit of giutamic acid. Arch. Dis. Child-hood, 26:487, 1951.

48. Sherwin, C. P., and Kennard, K. S. : Toxi-

city of phenybacetic acid. J. Biol. Chem.,40:259, 1919.

49. Bickel, H., Boscott, R. J., and Gerrard, J.:Observations on the biochemical errorin phenylketonuria and its dietary con-trol, in Proc. First Internat. Neurochemi-cal Symposium, Oxford, 1955, p. 417.

50. Boscott, R. J., and Bickeb, H. : Detectionof some new abnormal metabolites inthe urine of phenylketonuria. Scandinav.J. Clin. & Lab. Invest., 5:380, 1953.

51. Armstrong, M. D., and Robinson, K. S.:On the excretion of indole derivativesin phenylketonuria. Arch. Biochem.,52:287, 1954.

52. Armstrong, M. D., Shaw, K. N. F., and

Robinson, K. S. : Studies on phenylke-tonuria. II. The excretion of o-hydrox-yphenybacetic acid in phenyiketonuria.J. Blob. Chem., 213:797, 1955.

53. Udenfriend, S., and Mitoma, C. : Conver-

sion of phenylaianine to tyrosine, inSymposium on Amino Acid Metabolism,

McElroy, W. D., and Glass, H. C., cdi-tors. Baltimore, Johns Hopkins Press,1955, p. 876.

54. Dancis, J., and Balis, M. E. : A possiblemechanism for disturbance in tyrosinemetabolism in phenybpyruvic obigo-phrenia. PEDIATRICS, 15:63, 1955.

55. Miyamoto, M., and Fitzpatrick, T. B.:Competitive inhibition of mammaliantyrosinase by phenylalanine and its re-


CONGENITAL DEFECTS IN ADRENAL STEROID SYNTHESIS

By Alfred M. Bongiovanni, M.D.Children’s Hospital of Philadelphia, and Department of Pediatrics, University of Pennsylvania

This work was supported by a grant (EDC-25-A) from the American Cancer Society and by a grant(A-619) from the National Institute of Arthritis and Metabolic Disease, Public Health Service.

ADDRESS: 1740 Bainbridge Street, Philadelphia 46, Pennsylvania.


bationship to hair pigmentation in

phenylketonuria. Nature, 179: 199, 1957.56. Bickis, I. J., Kennedy, J. P., and Quasteb,

J. H. : Phenyialanine inhibition of tyro-sine metabolism in the liver. Nature,179:1124, 1957.

57. Weil-Malherbe, H. : Blood adrenaline andintelligence, in Proc. First Internat.

Neurochemical Symposium, Oxford,1955, p. 458.

58. Munier, R., and Cohen, G. N. : Incorpora-

tion d’anabogues structuraux d’amino-

acides dans les prot#{233}ines bact#{233}riennes.Biochim. et bioph�s. acta, 21:592, 1956.

59. Brawerman, G., and Y�as, M. : Incorpora-tion of the amino acid analog tryptazanillto the protein of Escherichia coil.

Arch. Biochem., 68:112, 1957.60. Tarver, H., and Gross, D. : Incorporation

of ethionine into the proteins of Tetra-hvmena. Fed. Proc., 14:291, 1955.

S CRUTINY of the adrenocortical steroidsexcreted in the urine of patients with

the adrenogenitab syndrome (due to con-

genital adrenal hyperplasia) has afforded

an opportunity to localize the biochemical

defects attributable to an inborn error of

metabolism and has elucidated the normal

pathway for biosynthesis in the adrenal

gland in man.�3 The studies of Hechterl on

the biogenesis of hydrocortisone in the beef

adrenal has indicated a stepwise oxidation

of progesterone toward the fulfillment of

the requirements for the final product,

namely hydrocortisone. Hydrocortisone is

indeed a “final product” in the economy of

the pituitary adrenal axis : When its rate of

secretion is low, larger amounts of adreno-

corticotropin (ACTH) are released in an at-

tempt to stimulate the adrenal cortex. If the

target gland cannot properly synthesize hy-

drocortisone, the pituitary continues to

stimulate the gland, which produces large

61. Block, R. J., Jervis, G. A., Boiling, D., andWebb, M. : The amino acid content oftissue proteins of normal and phenyb-pyruvic obigophrenic individuals. J. Biol.Chem., 134:567, 1940.

62. Schrappe, 0. : Zur pathobogischen Physiobo-gie des Phenybrenztrabensaure Sch-wachsinns. Nervenarzt, 23: 175, 1952.

63. Brown, D. M., Armstrong, M. D., andSmith, E. L. . Studies on phenylketonuriaIv. Serum proteins in phenylketonuria.Proc. Soc. Exper. Biol. & Med., 89:367,1955.

64. Hsia, D. Y., Driscoll, K. W., Troll, W.,and Knox, W. E. : Detection by pheny-lalanine tolerance tests of heterozygouscarriers of phenybketonuria. Nature, 178:1239, 1956.

65. Knox, W. E., and Hsia, D. Y. : Pathogeneticproblems in phenylketonuria. Am. J.Med., 22:687, 1957.

quantities of “abnormal” intermediary me-

tabolites. Certain of these latter substances

are androgenic and account for the clinical

manifestations.

An oxygen function must be introduced

into the progesterone molecule at carbons

17, 21 and 11 in order for the adrenal cor-

tex to manufacture hydrocortisone. The

oxygen is introduced at each position, pre-

sumably under the control of separate en-

zymes, tentatively termed “hydroxylases”

and specified by the position they

affect. If one or more of these enzymes

is lacking, hydrocortisone is not produced,

or is synthesized in limited quantities. Dc-

pending upon the particular enzymatic de-

feet, the unusual metabolites measured in

the blood and urine vary, as does the type

of disease encountered.

In all forms of the adrenogenital syn-

drome, virilization is present. The disease

is initiated in utero so that female infants


1958;21;1021Pediatrics Alton Meister


ServicesUpdated Information &

http://pediatrics.aappublications.org/content/21/6/1021including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlentirety can be found online at: Information about reproducing this article in parts (figures, tables) or in its

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:


http://http://pediatrics.aappublications.org/content/21/6/1021http://www.aappublications.org/site/misc/Permissions.xhtmlhttp://www.aappublications.org/site/misc/reprints.xhtml

1958;21;1021Pediatrics Alton Meister


http://pediatrics.aappublications.org/content/21/6/1021the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1958 by thebeen published continuously since 1948. Pediatrics is owned, published, and trademarked by the Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has


http://pediatrics.aappublications.org/content/21/6/1021

Documents

J. - Pediatrics · via the intermediate formation of phenyl-The enzyme that catalyzes reaction (3) ... ion-reactive substances of the blood, phe-nylalanine administration did not