Atypical variants of nonketotic hyperglycinemia

Clinical symptoms in atypical nonketotic hyperglycinemia (NKH) are heterogeneous, in sharp contrast to uniform severe neurological symptoms in the classical NKH. A review of the literature of atypical NKH cases reveals three forms: neonatal, infantile, and late onset. The presentation in the neonatal form is similar to the classical one but the subsequent outcome is significantly better. Mental retardation and behavioral abnormalities are prevalent in both infantile and late onset forms although the phenotype in late onset atypical NKH is more heterogeneous. Patients with the atypical NKH tend to have a lower CSF/plasma glycine ratio when compared with the classical form, but overlap occurs. Hyperglycinemia in the neonatal and infantile atypical NKH, similar to the classical form, is caused by a deficient glycine cleavage system, whereas the cause of hyperglycinemia in late onset atypical NKH is unknown. A mutation of the T-protein AMT gene and several mutations of P-protein GLDC gene have been identified in homozygous or compound heterozygous state. Some of the GLDC mutations are associated with residual glycine decarboxylase activity when expressed in COS7 cells and early therapeutic intervention may be crucial to improve the outcome in patients harboring such mutations. Identification of more mutations causing atypical NKH and information about the mutations' effect on enzyme activity may help to predict patients with a milder phenotype as well as those who may respond to early therapeutic intervention.