Treatment of an adrenomyeloneuropathy patient with Lorenzo's oil and supplementation with docosahexaenoic acid-A case report
© Terre'Blanche et al; licensee BioMed Central Ltd. 2011
Received: 25 July 2011
Accepted: 26 August 2011
Published: 26 August 2011
This is a case report of adrenomyeloneuropathy (AMN), the adult variant of adrenoleukodystryphy (ALD). The diagnoses in the patient, aged 34, was confirmed via increased serum very long chain fatty acid concentration (VLCFA). Treatment started with the cholesterol lowering drug, atorvastatin, followed by add-on therapy with Lorenzo's oil (LO) and finally supplementation with docosahexaenoic acid (DHA). The magnetic resonance imaging (MRI) scan of the AMN patient before DHA treatment, already showed abnormal white matter in the brain. Although the MRI showed no neurological improvement after 6 months of DHA treatment, no selective progression of demyelination was detected in the AMN patient. Contrary to what was expected, LO failed to sustain or normalize the VLCFA levels or improve clinical symptoms. It was however, shown that DHA supplementation in addition to LO, increased DHA levels in both plasma and red blood cells (RBC). Additionally, the study showed evidence that the elongase activity in the elongation of eicosapentaenoic acid (EPA) to docosapentaenoic acid (DPA) might have been significantly compromised, due to the increased DHA levels.
KeywordsAdrenoleukodystrophy Adrenomyeloneuropathy Lorenzo's oil Docosahexaenoic acid polyunsaturated fatty acids
Adrenomyeloneuropathy (AMN), one of the variants of X-linked adrenoleukodystrophy (X-ALD), is an inherited genetic disorder, classified as a single peroxisomal enzyme disorder that affects the peroxisomal β-oxidation pathway. Cerebral demyelination may develop in males and is confirmed via clinical and MRI evidence of inflammatory brain involvement . Biochemically, this disease is associated with the abnormal accumulation of saturated, very long chain fatty acids (VLCFA), especially C24:0 and C26:0 .
Although different therapies have been employed to treat X-ALD, there is currently no cure. Recent articles suggest cholesterol management as a potential treatment. In X-ALD patients, accumulation of VLCFA is mainly in the form of cholesterol ester fractions in ALD tissues, particularly the brain . It was demonstrated in a previous study that the HMG-CoA reductase inhibitor, lovastatin, caused a reduction in the VLCFA plasma levels of X-ALD patients . Therefore, it is contemplated that an interaction between cholesterol and VLCFA metabolism does exist . However, the exact mechanism is still unknown. Another alternative therapy consists of Lorenzo's oil (LO) (mixture of oleic and erucic acid) in combination with a diet low in VLCFA. Although VLCFA plasma levels of ALD patients were lowered within 4 weeks after treatment with LO , no improvement of neurological symptoms has been reported in the literature . Elevated levels of erucic and nervonic acids in plasma, as well as a reduction in docosahexaenoic acid (DHA) and eicosapentanoic acid (EPA) had been observed in patients treated with LO . Results from another study also indicated a decrease in DHA plasma levels after treating AMN patients with LO , leading to speculation that erucic acid could have an effect on the metabolism of DHA. The mechanism of action of Lorenzo's oil could be attributed to erucic acid that competes for the elongation of saturated fatty acids in the VLCFA synthesis pathway, resulting in a reduction of the VLCFA concentrations . Competition for the elongation enzyme in the DHA biosynthesis pathway by erucic acid could be a possible mechanism for decreased DHA levels observed with Lorenzo's oil treatment. In order to normalize the essential fatty acid depletion, supplementation with DHA is usually recommended .
The aim of this study, was to establish if supplementation with DHA in addition to treatment with LO, might increase plasma and red blood cell (RBC) DHA levels and improve clinical symptoms in a patient diagnosed with X-ALD (phenotype AMN).
A 28-year-old male patient started to complain about finding it difficult to walk as well as of bladder dysfunction. Magnetic Resonance Imaging (MRI) confirmed the diagnosis of a degenerative neurological disorder. At age 34, the diagnoses of ALD was confirmed at the laboratory for Inherited Metabolic Defects, School for Biochemistry, North-West University (Potchefstroom Campus), South Africa, as well as at the laboratory for Genetische Metabole Ziekten in Amsterdam, The Netherlands, via increased plasma levels of VLCFA (C26:0 and C24:0) as well as high ratios of C24:0/C22:0 and C26:0/C22:0.
The clinical picture was typical of the AMN phenotype. The following symptoms were present during physical examination: spastic paraparesis, ataxia, variable episodes of hypertonia and spasms, impotence (possibly related to the spinal cord involvement), intermittent behavioural changes and bladder dysfunction.
Approximately one year after diagnosis, brain involvement was again assessed by MRI. Even though abnormal white matter was clearly observed, the patient was diagnosed with the AMN phenotype. At that time, the neurological progression of the patient was also rated using the ALD-Disability Rating Scale . On that occasion, the patient was rated at number two, indicating that he did require some interventions. No adrenal insufficiency was noted with an ACTH stimulation test.
Treatment with the cholesterol lowering drug, atorvastatin (10 mg/day), and L-carnitine (2g/day) started immediately after diagnosis. After three months, LO (10 ml/day) was added to the treatment to effect inhibition of VLCFA elongation. This treatment continued for seven months (March 2008 to September 2008) and was then supplemented with DHA (600 mg/day in divided doses) for eight months. The DHA supplementation consisted of a mixture of medium chain triglyceride oil (MCT), fish oil (40% DHA, 5% EPA) and vitamin E as an antioxidant.
The VLCFA, phytanic and pristanic acid content in plasma, during all the treatment phases (cholesterol lowering, LO, DHA) and the polyunsaturated fatty acid (PUFA) content in plasma during LO treatment were determined. The effect of the DHA treatment was established by determining PUFA in both plasma and RBC and a clinical evaluation was carried out using an ALD-Disability Rating Scale and an MRI scan. The latter evaluations were done before and after DHA therapy started. Plasma concentrations of oleic and erucic acid were measured every month to corroborate compliance to the dietary treatment.
This case study was approved by the Ethics Committee of the North-West University (Potchefstroom Campus) (application number NWU-0038-08-S5). Informed consent was obtained from the patient for this case study.
The AMN patient fasted for 10 to 14 hours prior to the collection of blood samples. For analysis of the PUFA, blood samples were collected in vacutainers containing EDTA.
The method described by Evans and co-workers , was used for separating plasma and RBC and samples were stored at -80°C until analysis. Plasma and RBC were obtained from age matched healthy human subjects.
Analysis of saturated VLCFAs, in plasma
A modified method from Vreken and co-workers  was used for sample preparation and determination of VLCFAs. The samples were analyzed by GC/MS (Hewlett-Packard model 6890/5973 GC-MS system), equipped with a 120-0132 DB-1ms capillary column (30 m × 0.25 mm i.d. × 0.25 μm film thickness) (Agilent Technologies, Chemetrix, Midrand, South Africa).
Samples were injected into the GC/MS system with splitless mode and the carrier gas was helium. The electron impact ionization was applied at 0.7 eV and the mass spectrum with single ion monitoring (SIM) mode, was used to monitor the characteristic [M-57]+ ions . The oven temperature was programmed to start at a temperature of 60°C for 1 minute. The temperature was then increased to 240°C (30°C/min), followed by an increase to 270°C (10°C/min) and finally by an increase to 300°C (4°C/min) where it was maintained for 3 minutes. HP-chemstation software was used to quantify the raw data obtained from the GC/MS.
Analysis of PUFA in RBC
For the sample preparation of the RBC a modified version of the procedures by Takemoto and co-workers  and by Blau and co-workers  were used. The concentrations of the fatty acid methyl esters (FAME) in the RBC samples were analyzed by GC/MS (Agilent Technologies 6890N GC system and Agilent Technologies 5973 MS system) equipped with a capillary column (Agilent 19091S-433). The injector (7683 B Series) temperature was set at 250°C and helium was used as carrier gas. The RBC samples were injected into the GC/MS system with splitless mode. The oven temperature was initially set at 50°C and was increased to 190°C (30°C/min), then to 220°C (3°C/min), and finally to 230°C (6°C/min) and maintained for 24 minutes.
Identification of the PUFA peaks was carried out via AMDIS, an Automated Mass Spectral Deconvolution and Identification System. The mass spectra of the fatty acids were obtained from the National Institute of Standards and Technology (NIST) library.
Analysis of PUFA in plasma with TLC
The methods of Takemoto and colleagues  and Blau and co-workers , were modified for sample preparation. Purification of the samples was achieved by adapting the thin-layer chromatography method by Smuts and Tichelaar  for methyl esters. The samples were analyzed with a GC/MS (Agilent Technologies 6890N GC system and Agilent Technologies 5973 MS system) equipped with a capillary column (J&W 122-2361). The injector (7683 B Series) temperature was set at 250°C and helium was used as carrier gas.
The plasma samples were injected into the GC/MS system with split mode. The split ratio was set at 5:1 with a flow of 4.4 ml/min. The oven temperature was initially set to 160°C and increased to 220°C (3°C/min) where it was maintained for 15 minutes. Samples were quantified with Chemstation Enhanced Data analysis software (version D.01.XX) using unique single ions and calibration curves for each FAME.
Results and discussion
Subsequently, the increased DHA and EPA levels could also lead to an anti-inflammatory effect. DHA and EPA competitively inhibit the oxygenation of arachidonic acid (C20:4 n-6; AA) , thereby decreasing production of AA-derived eicosanoids. DHA reduces C20:4 n-6 biosynthesis via the inhibition of Δ5 or Δ6 desaturase , whereas EPA displaces C20:4 n-6 from phospholipids. The present study also confirmed the inhibition of Δ6 desaturase, as is indicated by the decreased plasma ratio, C18:3 n-6/C18:2 n-6, after one month of DHA supplementation (data not shown).
In conclusion: it was confirmed that supplementation with DHA, in addition to LO and treatment with a cholesterol lowering drug, atorvastatin, increased DHA levels in plasma and RBC of the AMN patient. These increased DHA levels may exert a neuro-protective effect by a negative feedback mechanism, leading to an increase in EPA. In turn, EPA and DHA are incorporated into inflammatory cell phospholipids, partly at the expense of AA, exerting an anti-inflammatory effect . Sing and Pujol also suggested that treatment strategies should be developed for the inflammatory, metabolic and oxidative stress disease aspects of X-ALD . Supplementation with DHA, is therefore strongly recommended in patients with X-ALD patients, due to the important role of DHA in brain development and myelination and the feedback mechanism which may cause a neuro-protective and anti-inflammatory effect.
very long chain fatty acid
magnetic resonance imaging
red blood cell
polyunsaturated fatty acid
fatty acid methyl esters
We would like to thank the National Research Foundation (NRF) for their financial support. Thanks also go to the laboratory for Inherited Metabolic Defects, School for Biochemistry, North-West University, South Africa for allowing us to use their equipment.
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