Differential diagnosis of homocystinuria by urease treatment, isotope dilution and gas chromatography–mass spectrometry

Homocystinuria types I, II and III are characterized by different etiologies, biochemical abnormalities and therapeutic measures. For this reason, differential diagnosis is critical for effective treatment. We describe here a rapid and simple procedure for establishing a differential diagnosis of the three types of homocystinuria by analyzing the urine of patients. This procedure, which consists of urease treatment, stable isotope dilution and GC–MS, enables a simultaneous quantification of methionine, homocystine, cystine, methylmalonate, orotate, uracil and creatinine. Analysis with this procedure showed that a case of homocystinuria type I, who progressed into transient megaloblastic anemia, secondarily excreted an increased concentration of orotate, which normalized after treatment with folate and vitamin B12. Therefore, the present diagnostic procedure not only enables rapid differential diagnosis of homocystinuria, but also should prove useful for monitoring the disease state and understanding the nutritional condition and therapeutic state of patients, which in turn can be used to evaluate the efficacy of treatment.