Abstract
We are reporting monochorionic, diamniotic twin premature infants born at 25 weeks and 6 days gestation with riboflavin (vitamin B2) and biotin (vitamin B7) deficiency, while on prolonged total parenteral nutrition (TPN) during vitamin shortage. They presented initially with skin rash, lactic acidosis, and thrombocytopenia. Both twins progressed to severe respiratory failure, severe lactic acidosis, with refractory vasodilatory shock, pancytopenia, ischemic bowel injury, acute kidney injury, liver injury, and capillary leak syndrome leading to death of twin A. The surviving twin B was diagnosed with riboflavin and biotin deficiency that presented with abnormal metabolic work up suggestive of maple syrup urine disease, glutaric acidemia type 2, and X-linked adrenoleukodystrophy. Twin B was started on riboflavin and biotin supplementation at 41 days of life, with rapid improvement in clinical findings and laboratory abnormalities within days of starting biotin and riboflavin supplementation. He was discharged home in stable condition at 49 weeks of postmenstrual age.
Introduction
Extremely preterm infants (<28 weeks of gestation) are at high risk for feeding intolerance requiring total parental nutrition (TPN) for an extended period. A significant shortage of vitamins supplementation for use in TPN was encountered since the beginning of the coronavirus disease-2019 (COVID-19) pandemic. During that period, in our hospital, we provided a modified multivitamins cocktail containing thiamine 100 mg/mL, folic acid 5 mg/mL, ascorbic acid 500 mg/mL, pyridoxine 100 mg/mL, and vitamin K 200 mcg/mL. Riboflavin (vitamin B2) and biotin (vitamin B7) were not included in the multivitamin supplementation cocktail, both are essential water-soluble vitamins available in infant formula and breast milk.1-5 There is very limited information about riboflavin and biotin deficiency in extremely preterm infants.
Case report
Monochorionic, diamniotic twins delivered prematurely at 25 weeks and 6 days gestation by cesarian section and were admitted to our Level III Neonatal Intensive Care Unit (NICU) at Los Angeles County + USC Medical Center in October 2021. Verbal Health Insurance Portability and Accountability Act (HIPAA) authorization and informed consent were obtained from the mother of the twins (legally authorized representative) for anonymized information of the patients to be published in this article, per the recommendations of our Institutional Review Board. Detailed maternal and neonatal clinical characteristics are shown in Table 1. Both premature infants developed respiratory distress syndrome (RDS), received surfactant, mechanical ventilation (short term), and then were managed with noninvasive positive pressure ventilation (NIPPV). Both developed severe hypotension and required epinephrine, dobutamine, dopamine, and hydrocortisone, they were weaned off vasopressors and hydrocortisone over the first week of life.
Maternal and Neonatal Clinical Characteristics.
Abbreviations: RDS, respiratory distress syndrome; MSUD, maple syrup urine disease; GAT2, glutaric aciduria type 2.
They were on TPN immediately after birth, but establishment of enteral feedings was challenging due to feeding intolerance. Blood lactate level was normal at birth in both twins; however, gradually increased by day of life 12 to 16 accompanied by erythematous patches on the abdomen, face, and lower extremities associated with leukopenia and thrombocytopenia. A sepsis work up, vitamins, and metabolic disease work up were sent, and they were treated with antibiotics. Blood culture came back positive for Staphylococcus aureus in twin B. Repeat blood culture was negative after antibiotic treatment in both patients. Overtime, their clinical status worsened with similar clinical and laboratory findings occurring at the same time or within a day from each other.
Twin A: He had a normal blood lactate level at birth; however, it gradually increased by day of life 16 to 11 mmol/L with a maximum of > 17 mmol/L at 35 days of age. This refractory lactic acidosis persisted throughout the hospital stay despite treatment including a high infusion rate of sodium bicarbonate. On day of life 12 pancytopenia associated with erythematous patches all over the body were noted. Severe pancytopenia persisted and required daily granulocyte-colony stimulating factor (G-CSF) and frequent platelet and packed red blood cells (PRBCs) transfusions. Because of worsening respiratory distress, he was placed on invasive high frequency jet ventilation (HFJV), he also developed severe vasodilatory shock requiring treatment with catecholamines, volume expanders, and hydrocortisone. Abnormal abdominal X-ray findings led to exploratory laparotomy on day of life 28, which revealed volvulus with necrotic bowel, 33 cm of terminal ileum were resected. Clinical status deteriorated over time to refractory vasodilatory shock, severe capillary leak syndrome, and progressed to multiorgan failure leading to withdrawal of care on day of life 40 prior to administration of supplemental vitamins (riboflavin and biotin).
Twin B: Following a normal blood lactate level at birth, severe lactic acidosis to as high as 10 mmol/L at 12 days and 14.7 mmol/L at about 4 weeks of age (Figure 1), and diffuse scaly red patches all over the body and face with scalp hair thinning and hair loss were present. A dose of thiamine 100 mg was given without any effect on the level of lactate. Twin B also developed worsening respiratory distress requiring invasive HFJV, and he developed severe vasodilatory shock requiring dopamine, epinephrine, volume expanders, and hydrocortisone. Abdominal films of twin B showed dilated fixed loops, leading to exploratory laparotomy on day of life 29. He had ischemic bowel injury without necrosis, 22 cm of ileum were resected. Ongoing refractory lactic acidosis persisted despite high infusion rate of sodium bicarbonate as high as 1 mEq/kg/hr. Twin B also had severe prolonged pancytopenia with neutrophil count as low as zero requiring daily G-CSF, platelets as low as 30 K/cumm requiring platelet transfusions every 3 days and PRBCs transfusions every 4 to 7 days. He also had acute kidney injury with blood urea nitrogen (BUN) as high as 105 mg/dL and creatinine 1.8 mg/dL, and liver injury with direct bilirubin of 15.4 mg/dL and aspartate aminotransferase (AST) as high as 211 U/L.
Serial arterial lactate levels during the first 45 days of life in twin B.
Serum amino acids and acylcarnitine profiles at 29 days of age showed significantly elevated branched chain amino acids in both twins (Twin A/B: leucine 453/1886, isoleucine 243/945, valine 436/1490, alloisoleucine 10/56, umol/L) suggestive of maple syrup urine disease (MSUD), and markedly increased multiple acylcarnitines with glutarylcarnitine being the most prominently elevated suggestive of glutaric aciduria type 2 (GAT2) or the riboflavin transporter defect. Urine organic acid analysis showed elevated concentrations of pyruvate, 3-hydroxypropionate, 3-hydroxyisovalerate, glutarate, and 2-hydroxyglutarate in addition to branched chain alpha-ketoacids. These findings were suggestive of riboflavin and biotin deficiency. The California Newborn Screening on day 37 in Twin B showed abnormal serum amino acids and acylcarnitine profiles consistent with the previous laboratory studies, and also reported abnormal very long chain fatty acids suggestive of X-linked adrenoleukodystrophy.
Riboflavin and biotin levels in twin B came back low at < 0.5 nmol/L (normal 6.2-39 nmol/L) and <100 pg/mL (normal 100-2460.2 pg/mL), before supplementation with these vitamins which were initiated on day 41 of life. Riboflavin (vitamin B2) supplementation was started at 10 mg IV daily and biotin (vitamin B7) at 1 mg IV daily in twin B. Within 48 hours of administration, vasopressors and continuous sodium bicarbonate infusion were discontinued, and within 90 hours the infant was extubated to NIPPV. Renal function recovered in a week while liver function normalized in a month. All abnormal metabolites identified in serum amino acids and urine organic acids responded promptly and were normalized within 9 days after initiation of riboflavin and biotin supplementation, while very long chain fatty acids normalized after 15 days. Twin B was discharged home at 49 weeks of postmenstrual age stable in room air.
Discussion
Pregnant mothers are at risk for biotin deficiency especially if not taking 2 to 3 times the recommended biotin intake.1,2 Riboflavin deficiency can lead to migraine, mucus membranes edema, cheilosis and glossitis, seborrheic dermatitis, neuropathy, cataract, anemia, and neurodevelopmental delay. 3 Biotin deficiency presents with alopecia, erythematous dermatitis, acidemia, aciduria, vision, and neurosensory hearing loss, and neurodevelopmental delay. 4 There are very limited information on riboflavin and biotin deficiency in premature infants, especially in extremely preterm infants.
Riboflavin and biotin are water soluble vitamins involved in multiple essential metabolic pathways. Riboflavin plays a major role in mitochondrial oxidation of amino acids, fatty acids, and glucose. 3 Riboflavin is also essential to the formation of coenzymes flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD), both play a major role in respiratory chain complex 2 pathway. Biotin is a coenzyme for the carboxylases (pyruvate carboxylase, propionyl-CoA carboxylase, and acetyl-CoA carboxylase). 4 Inhibition of these essential enzymes resulted in the combination of specific metabolic profiles, that is, MSUD, glutaric aciduria type 2, and X-linked adrenoleukodystrophy. The severe lactic acidosis, bone marrow suppression (thrombocytopenia and leukopenia), and generalized rash seen in both twins were likely due to the inhibition of biotin derived carboxylases.
Riboflavin is an essential vitamin that plays a major role in the function of other vitamins. 5 Premature infants are at high risk for riboflavin deficiency due to several factors including exposure to prolonged phototherapy, 6 use of banked breast milk in infant feeding, 7 poor absorption, and maternal riboflavin deficiency which occurs frequently if low amounts of dairy or meat products are consumed.3,5,8 Infants born to mothers with riboflavin deficiency or riboflavin transporter mutation are at risk for transient neonatal onset of glutaric aciduria type 2.5,8,9
Biotin deficiency also plays a major role in inflammation, it up-regulates tumor necrosis factor-α (TNF-α) production in murine macrophages. 10 Also alters the spleen lymphocytes subpopulation and blocks thymocytes maturation and accelerates thymus involution in mice.11,12 Agrawal et al, investigated the effects of biotin deficiency on monocyte derived dendritic cells cultured in biotin deficient media and then activated by lipopolysaccharide (LPS) leading to enhanced secretion of TNF- α, and several interleukins (IL-12p40, IL-23, and IL-1β). 13 Proinflammation associated with biotin deficiency might explain the inflammatory bowel injury, rash, capillary leak syndrome, and vasodilatory shock. Severe lactic acidosis has been shown to decrease myocyte’s intracellular calcium and myofibril’s calcium sensitivity, leading to decreased left ventricular function, vascular myocyte tone, and vasopressors refractory shock as was the case in our twins.14-16
Riboflavin responsive anemia was first described in 1953. 17 Riboflavin deficiency leads to erythrocyte hypoplasia, reticulocytopenia, and decreased ferritin mobilization in tissues,18,19 and not much has been reported about its association with thrombocytopenia and neutropenia; however, with riboflavin and biotin supplementation all blood cell lines recovered quickly in our patient (twin B). Regarding liver and acute kidney injury, they were possibly due to severe hypotension and shock. However, an association with biotin or riboflavin deficiency cannot be ruled out since liver and kidney function recovered shortly after starting vitamin supplementation in twin B.
In summary, riboflavin and biotin storage in premature infants are limited and get depleted quickly after birth without supplementation. Deficiency of these vitamins in premature infants may lead to metabolic abnormalities that mimic MSUD, GAT2, and X-linked adrenoleukodystrophy. Prolonged TPN use without supplementation of riboflavin and biotin (as may occur during vitamin shortage) is harmful and can be fatal. Early administration of riboflavin and biotin to premature infants on prolonged TPN is recommended, and high dose of riboflavin and biotin may be warranted in ill premature infants presenting with rash and unknown etiology of severe lactic acidosis, especially if associated with cardiorespiratory instability.
Footnotes
Acknowledgements
The authors would like to thank all our neonatologists, neonatal fellows, and all the staff members of our Neonatal Intensive Care Unit for the great care provided to our patients.
Author Contributions
Dr. Adie conceptualized and designed the case report, drafted the initial manuscript, and reviewed and revised the manuscript. Drs. Martes Gomez, Yom, Durand, Wertheimer, McGowan, Yano, and Ramanathan conceptualized and designed the case report, reviewed and revised the manuscript, and critically reviewed the manuscript for important intellectual content. All authors listed on the title page have fulfilled the conditions required for authorship and approved the submitted manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
This case report complies with the guidelines for human studies and was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.
Informed Consent
Verbal HIPAA (Health Insurance Portability and Accountability Act) authorization and informed consent were obtained from the mother of the twins (legally authorized representative) for anonymized information of the patients to be published in this article, per the recommendations of our Institutional Review Board.
