Rhode Island Medical Home Portal

Introduction

Here you’ll find answers to some of the questions that parents often have about this condition. Additional resources are listed at the bottom of the page. Diagnosis and management information can be found in the Homocystinuria module, which is written for primary care clinicians but also may be of help to parents and family members. Information can also be found in the Homocystinuria Newborn Screening Page.

What is homocystinuria and what causes it?

Homocystinuria is an autosomal recessive inherited metabolic disorder caused by a defect in an enzyme that converts the amino acid homocysteine to cystathionine, resulting in accumulation of homocysteine in the blood and its excretion in urine. There are two main variants or types of homocystinuria: one is responsive to vitamin B6 (pyridoxine, the cofactor of cystathionine beta synthase) and the other does not respond to vitamin B6 and usually has more-pronounced symptoms than the first variant. It may affect the cardiovascular, musculoskeletal, and the central nervous systems. [American: 2012]

What are the symptoms of homocystinuria?

With early treatment, there may be fewer symptoms and complications. Without treatment, symptoms vary widely.

Initial symptoms in infants and toddlers may include:

developmental delay
emotional and behavior problems
ectopia lentis (dislocation of the ocular lens) or severe myopia (nearsightedness)

Findings in older children and adults may include:

Marfanoid habitus: tall/thin build; long fingers, arms, and legs
genu valgum (knocked knees), pes cavus (high arch/instep)
osteoporosis (weak/brittle bones)
malar flush (red cheeks)
decreased hair, skin, iris pigmentation
seizures
vascular disease and stroke
psychiatric abnormalities
intellectual disabilities

How is it diagnosed?

Newborn metabolic screening measures an elevation of methionine that increases with homocysteine in affected individuals. Infants with milder variants, or in whom newborn screening is obtained too early, can be missed by newborn screening. There are many other types of homocystinuria caused by defects in the remethylation of homocysteine to methionine. These cases are not identified by most newborn screening programs because methionine is low and most programs do not have a low cut-off for methionine. The metabolic geneticist will test affected individuals to determine which variant is present. See the Portal's Newborn Disorder page on Homocystinuria for more information and response to a positive newborn screen.

What is the prognosis?

Infants identified by newborn screening and treated to correct the biochemical abnormalities appear to have fewer manifestations of the condition, including decreased incidence of intellectual disability and thromboembolic events. [Yap: 2000]

What is the risk for other family members or future babies?

Children from the same father and mother as the affected infant have a 1 in 4 chance of having homocystinuria. [New: 2010] Siblings of children with this condition should be screened with plasma amino acids and total plasma homocysteine. If the disease-producing mutation in the family has been identified, carrier testing can be performed.

What treatments/therapies/medications are recommended or available?

Blood levels of homocysteine are maintained as close as possible to the normal range by restricting methionine in the diet (usually through restricted protein intake) and adding methylfolate and methyl B12 supplementation, betaine treatment, and vitamin B6 (pyridoxine) supplementation. This treatment needs to be continued and monitored throughout life. Other individuals may benefit by antiplatelet treatment such as daily baby aspirin. Eye complications are treated surgically. Other complications are treated symptomatically (psychiatric problems, osteoporosis, etc.). Children with significant disabilities should receive developmental therapies.

How will my child and our family be impacted?

The family will be important in helping the child maintain a low-protein diet, restricting bread, pasta, eggs, dairy products, rice, nuts, and meat. Special formulas/powders are available with essential amino acids and no methionine or cystine. Keeping a diet record and completing blood tests will help manage the condition.

Can I breastfeed my baby who has just been diagnosed with homocystinuria?

Breastfeeding an infant with homocystinuria usually needs to be limited and should be discussed in detail with the metabolic genetics team. Formulas are usually used to supplement breastfeeding in order to limit methionine.

Resources

Information & Support

Where can I go for further information?

For Parents and Patients

Homocystinuria - Information for Parents (STAR-G)
A fact sheet, written by a genetic counselor and reviewed by metabolic and genetic specialists, for families who have received an initial diagnosis of this newborn disorder; Screening, Technology and Research in Genetics.

Homocystinuria (Genetics Home Reference)
Excellent, detailed review for patients and families affected by homocystinuria; a service of the U.S. National Library of Medicine.

Parent Information Sheet Homocystinuria - Confirmed Diagnosis (NHS) ( PDF Document 336 KB)
Information for parents for when the results of the newborn blood spot screening are positive; National Institute for Health Research (UK).

Homocystinuria Guide for Parents (NECMP)
Information about homocystinuria for patients, including inheritance, diagnosis, maintaining a healthy diet, treatment, and testing of other children; from the New England Consortium of Metabolic Programs.

Boston Children’s Hospital Transition Toolkit for Homocystinuria ( PDF Document 389 KB)
Includes health readiness assessments, metabolic conditions basics, and a transition plan for youth with homocystinuria. Sponsored by the New England Consortium of Metabolic Programs.

Tools

Care Notebook (UT Dept. of Health) ( PDF Document 467 KB)
For families to track your child's care, health, and other information; with pages from 10 different states. Word document may be edited.

Transition Toolkit for Metabolic Conditions (NECMP)
Includes health readiness assessments, metabolic conditions basics, and a transition plan for youth with metabolic conditions; New England Consortium of Metabolic Programs.

Services

Developmental Pediatrics

We currently have no Developmental Pediatrics service providers listed; search our Services database for related services.

Early Intervention for Children with Disabilities/Delays

See all Early Intervention for Children with Disabilities/Delays services providers (13) in our database.

Head Start/Early Head Start

See all Head Start/Early Head Start services providers (6) in our database.

Newborn Screening Programs

We currently have no Newborn Screening Programs service providers listed; search our Services database for related services.

For other services related to this condition, browse our Services categories or search our database.

Authors & Reviewers

Initial Publication: July 2014; Last Update: December 2015

Current Authors and Reviewers (click on name for bio):

Reviewer:

Meghan Candee, MD

Authoring history

(Limited detail is available on authoring dates before 2014.)

^AAuthor; ^CAContributing Author; ^SASenior Author; ^RReviewer

Page Bibliography

American College of Medical Genetics.
Homocystinuria: transition to adult health care ACT sheet.
2012; 2. https://www.acmg.net/StaticContent/ACT/Homocystinuria_Transition.pdf
Educational resource for clinicians providing care for patients with homocystinuria.

New England Consortium of Metabolic Programs.
Homocystinuria: a guide for parents of babies recently screened for homocystinuria.
(2010) http://newenglandconsortium.org/for-families/other-metabolic-disorders.... Accessed on July 2014.

Yap S, Naughten ER, Wilcken B, Wilcken DE, Boers GH.
Vascular complications of severe hyperhomocysteinemia in patients with homocystinuria due to cystathionine beta-synthase deficiency: effects of homocysteine-lowering therapy.
Semin Thromb Hemost. 2000;26(3):335-40. PubMed abstract