Recessive Congenital Methaemoglobinaemia: Three New Mutations in the NADH-Cytochrome b5 Reductase Gene.

Recessive congenital methemoglobinemia (RCM) is caused by deficiency of reduced nicotinamide adenine dinucleotide (NADH)-cytochrome b5 reductase (cytb5r). The cytb5r gene (DIA1) is localized on chromosome 22q13-qter and contains nine exons; tissue-specific alternative transcripts originate 275-amino acid soluble and 300-amino acid membrane-bound isoforms. Cytb5r deficiency exists in two distinct clinical forms: in Type-I the enzyme deficiency is restricted to the red cell-soluble cytb5r isoform and results in cyanosis; in Type-II the enzyme defect involves both the soluble and membrane-bound isoforms, and severe neurological impairment is also present. More than 40 different mutations of DIA1 gene have been reported in RCM: disruptive mutations (stop, frameshift, splicing) are in general associated with the severe Type-II disease. We report the clinical, hematological and molecular characterisation 6 new patients affected by RCM (Table 1). Mutations reported in italic are new. The study of cytb5r enzyme showed a drastic reduction of activity in all patients. Parents displayed intermediate values characteristics of an heterozygous state. Mutation IVS5+2 t-c at the homozygous state was found in Type-II RCM (case 1) as already reported by Yilmaz et al (2005) in one patient; this variant is likely to cause alteration of mRNA splicing and subsequent absence of functional protein in all tissues, therefore accounting for the severe clinical pattern. V252M is the most common DIA1 gene mutation and has been reported in both Type-I and -II homozygous patients; the finding that this mutation in association with the new, very disruptive Gln28STOP mutation results in a benign phenotype (case 4), suggests that V252M is more likely to behave as a “Type-I” mutation. In case 6, in spite of cyanosis present since childhood, diagnosis of RCM Type-I was made in adult age because of polycythemia. In fact, significant compensatory elevation of hemoglobin concentration is sometimes observed in patients with congenital methemoglobinemia.