A gene testing challange

[nandixon]

I think @Freddd almost certainly has a late-onset cobalamin deficiency type C (cblC) defect. So he probably has one or more significant mutations on the MMACHC gene. @richvank mentioned this several times before his passing.

Unfortunatey, there are several hundred SNPs on that gene, and several dozen mutations on it have been found that cause cblC deficiency. 23andMe only tests for a handful (9 on the v3 chip, maybe less on the current v4 version), so he'd need to have that gene sequenced.

I'm sure a research institution would be willing (and happy) to do this. He might want to see a genetics counselor who could act as a liaison. I did something similar several years ago with an unrelated mutation that I have.

A cblC defect easily explains all of his symptoms and various reactions to different supplements, for example: why he can't use cyanocobalamin; why he needs such large amounts of both methylcobalamin and adenosylcobalamin; why taking glutathione and N-acetylcysteine supplements cause excessive excretion of his B12, etc.

Here are just a few of many references on this:

Cobalamin C defect: natural history, pathophysiology, and treatment
http://www.ncbi.nlm.nih.gov/pubmed/20632110/

Three new cases of late-onset cblC defect and review of the literature illustrating when to consider inborn errors of metabolism beyond infancy
http://www.ncbi.nlm.nih.gov/pubmed/25398587/

Spectrum of mutations in MMACHC, allelic expression, and evidence for genotype-phenotype correlations
http://www.ncbi.nlm.nih.gov/pubmed/19370762/

Glutathione metabolism in cobalamin deficiency type C (cblC)
http://www.ncbi.nlm.nih.gov/pubmed/23568438/

Protection of aquo/hydroxocobalamin from reduced glutathione by a B12 trafficking chaperone
http://www.ncbi.nlm.nih.gov/pubmed/21429294/

 

[Freddd]

I think @Freddd almost certainly has a late-onset cobalamin deficiency type C (cblC) defect. So he probably has one or more significant mutations on the MMACHC gene. @richvank mentioned this several times before his passing.

Unfortunatey, there are several hundred SNPs on that gene, and several dozen mutations on it have been found that cause cblC deficiency. 23andMe only tests for a handful (9 on the v3 chip, maybe less on the current v4 version), so he'd need to have that gene sequenced.

I'm sure a research institution would be willing (and happy) to do this. He might want to see a genetics counselor who could act as a liaison. I did something similar several years ago with an unrelated mutation that I have.


A cblC defect easily explains all of his symptoms and various reactions to different supplements, for example: why he can't use cyanocobalamin; why he needs such large amounts of both methylcobalamin and adenosylcobalamin; why taking glutathione and N-acetylcysteine supplements cause excessive excretion of his B12, etc.

Here are just a few of many references on this:

Cobalamin C defect: natural history, pathophysiology, and treatment
http://www.ncbi.nlm.nih.gov/pubmed/20632110/

Three new cases of late-onset cblC defect and review of the literature illustrating when to consider inborn errors of metabolism beyond infancy
http://www.ncbi.nlm.nih.gov/pubmed/25398587/

Spectrum of mutations in MMACHC, allelic expression, and evidence for genotype-phenotype correlations
http://www.ncbi.nlm.nih.gov/pubmed/19370762/

Glutathione metabolism in cobalamin deficiency type C (cblC)
http://www.ncbi.nlm.nih.gov/pubmed/23568438/

Protection of aquo/hydroxocobalamin from reduced glutathione by a B12 trafficking chaperone
http://www.ncbi.nlm.nih.gov/pubmed/21429294/

Hi Nandixon,

I "survived" decades on CyCbl and clearly do not have Cobalamin C disease. It was Metafolin that brought my MCV down, not MeCbl. My body had B12 but not enough active folate to use it. What I can't use is vegetable folates. Without the l-methylfolate & MeCbl for methylation and AdoCbl and LCF for ATP the CyCbl I take in can't be converted to MeCbl because of the deadlock. The deadlock points back at folate problems, not CyCbl. Folic acid makes me sick quickly. However, It will be interesting to see. The problem is once again decades of research on CyCbl, HyCbl and folic acid. There is a lack of actually recognizing what active folate and active b12 deficiencies actually look like because of decades of misdirected research and the wrong assumptions produced by that research.

A few other matters. The large amount of MeCbl/AdoCbl I need is not for my body. As research has shown there is a problem with transport of cobalamins into the CSF in people with CFS, FMS, MS. Parkinson's, ALS, Supra Nuclear Palsy. That is way too common to be cobalamine C disease which is rare. Also, virtually everybody who has tried both, first the MeCbl until equilibrium is reached, and then AdoCbl, the AdoCbl has a separate response in almost everybody. Personally I have a significant amount of AdoCbl converted from MeCbl and only need it once every week or two to get it into my CNS. Others who need a large amount of AdoCbl every day have something different going on.

HyCbl gives me acne in days and appears to cause partial methylation block and faulty cell reproduction. CyCbl doesn't do that to me. Folic acid is much worse and faster at causing problems.

I will read these when I get a chance. However, the COB C disease hypothesis went back to my earliest days here from Rich and that has been wrong since the beginning. I lacked the failure to thrive that usually kills such children.

Thank you for putting forth your hypothesis. I have put forth mine regarding these and we will see what turns up.

What I would be very interested in is finding out why the transport of cobalamin into CSF is so faulty with us folks who end up getting these diseases.

 

[nandixon]

Cobalamin C deficiency still fits perfectly for you. Individuals with cblC defects also show lower intracellular folate levels.

Just as one literature example (which in addition also mentions your own finding of ineffectiveness of OHCbl):

In the present study we show that cultured skin fibroblasts from cblC patients export increased levels of both homocysteine and methylmalonic acid compared to control skin fibroblasts, and that they also have decreased levels of total intracellular folates. This is consistent with the clinical phenotype of functional cobalamin deficiency in vivo... Supplementation of the cell cultures with hydroxocobalamin did not restore the cblC proteome to the patterns of expression observed in control cells. These results concur with the observed phenotype of patients with the cblC disorder and their sometimes poor response to treatment with hydroxocobalamin...

THE MMACHC PROTEOME: HALLMARKS OF FUNCTIONAL COBALAMIN DEFICIENCY IN HUMANS http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110603/

Really, the diagnostic clincher is how for you, personally, taking normal amounts of supplemental glutathione or NAC causes pathological vitamin B12 deficiency.

That doesn't happen in a normal person, i.e. one without a defect in the MMACHC gene, because it is the very cblC protein (produced by that gene) itself that specifically protectively regulates the interaction of glutathione with cobalamin and prevents the problem you experienced. (See the whole series of articles, 2011-2015, by the South Korean researchers who describe cblC as a "trafficking chaperone" for cobalamin with respect to glutathione.)

 

[Freddd]

Cobalamin C deficiency still fits perfectly for you. Individuals with cblC defects also show lower intracellular folate levels.

Just as one literature example (which in addition also mentions your own finding of ineffectiveness of OHCbl):

THE MMACHC PROTEOME: HALLMARKS OF FUNCTIONAL COBALAMIN DEFICIENCY IN HUMANS http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110603/

Really, the diagnostic clincher is how for you, personally, taking normal amounts of supplemental glutathione or NAC causes pathological vitamin B12 deficiency.

That doesn't happen in a normal person, i.e. one without a defect in the MMACHC gene, because it is the very cblC protein (produced by that gene) itself that specifically protectively regulates the interaction of glutathione with cobalamin and prevents the problem you experienced. (See the whole series of articles, 2011-2015, by the South Korean researchers who describe cblC as a "trafficking chaperone" for cobalamin with respect to glutathione.)

I'm finding these things rather convincing and am getting a summary going for my appointment in 3 days with new doc. I will respond further when I get a chance. Thank you for this info.

 

[Freddd]

(See the whole series of articles, 2011-2015, by the South Korean researchers who describe cblC as a "trafficking chaperone" for cobalamin with respect to glutathione.)

Hi Nandixon,

Can you give me a link to those?

 

[Freddd]

@nandixon

One of the things they mention in these is the extreme heterogenic nature of adult onset symptoms of CblC problems, which comes in many flavors, and that there is in the adults, something that triggers the active condition. Why is that not a surprise.

For instance one of the common problems is excess metabolic ammonia, something I didn't have that I know of but plenty of people here talk about. Then there are kidney problems and hypertension with Nephritis, possibly
Potassium-losing Nephritis considering the that there are electrolyte management problems also mentioned and might be one of my problems.

 

[nandixon]

Hi Nandixon,

Can you give me a link to those?

This search picks up most of the work, I think:
http://www.ncbi.nlm.nih.gov/pubmed/?term=trafficking+chaperone+cobalamin

 

[Johnmac]

Fred, as I recall Rich predicted that you would have an MTHFS SNP because of your problem with folinic acid.

 

[ahmo]

I have this MTHFS, and problems w/ folinic.

 

[Freddd]

Really, the diagnostic clincher is how for you, personally, taking normal amounts of supplemental glutathione or NAC causes pathological vitamin B12 deficiency.

Hi Nandixon,

I'm not sure this is the clincher however. I think the rate at which it occurs is the clincher. Going back to that N=10 trial. The BIG difference in onset of the glutathione/NAC effects was the speed. I had methyltrap symptoms start in hours, harder and faster than the others. The problem is 100% had the same response within 1-2 weeks and all were similarly damaged in 6 weeks. As these articles say there are many unknown variations on the gene and heterogeneous manifestations. I think it works hand around the carotid artery with MTHR polymorphisms of which they make no mention. Perhaps the MTHR problems are what triggers adult onset. You look at my history and it is very similar except more symptoms faster and harder than most. I had FMS onset after a traumatic injury and sudden CFS onset with a "misc entero virus". So this one CblC protein is supposed to protect perhaps 2-10 mcgs of cobalamin in serum. How much of the CblC protein exists in a person? Is it just a matter of a few mgs of glutathione to completely overwhelm it? Tests in cultured cells don't give those answers. There is NOTHING at all I have come across that gives any indication that glutathione is safe for anybody. It could just all be dose related and what we see is a response curve with me at one toe and the bulk of the people needing 10x as much to cause problems or whatever. So on a "normal" dose it takes hours for me to go into methyltrap and for some others it takes a week to go into methyltrap. Is that what distinguishes CblC disease, the rate of going into methyltrap from glutathione? Perhaps there is a test that can detect that. Load up a person with a few days of injecting enough MeCbl for easy visibility and then give a dose of Glutathione. If there is increased visibility we know it is excreting B12. Isn't HTC2 supposed to protect B12 from chemical assault? That can account for a few mcg protected. For me the few mcg in the HTC2 is immaterial to my needs. I need plenty of free MeCbl and free AdoCbl and maybe that is what isn't protected. Does excreting the free B12 make a difference for others without some of the genetic polymorphisms affecting CblC?

There are a whole lot more questions than answers. Also, in reading I see they don't have a handle on how to treat this and have generally "poor" results with adult onset with their current nutritional treatment. I'd be dead if I were following their suggested treatment protocols. They haven't gotten their heads out of the HyCbl echo chamber that I can see and have no concept of methylfolate and they have botched the carnitine part and have no understanding of that yet.

 

[Freddd]

Fred, as I recall Rich predicted that you would have an MTHFS SNP because of your problem with folinic acid.

Hi Johnmac,

I know my folate needs are really whacked. I'm sure that all the many variations are due to all these other polymorphisms in connection to the one they have spotted.

 

[nandixon]

...So this one CblC protein is supposed to protect perhaps 2-10 mcgs of cobalamin in serum. How much of the CblC protein exists in a person? Is it just a matter of a few mgs of glutathione to completely overwhelm it?...

With a defective CblC protein (caused by a defect in the MMACHC gene), then what would be happening is that that protein/enzyme (it's both a carrier and an enzyme) may not "hold" onto the B12 correctly, allowing it to be released inappropriately and/or inappropriately react with reduced glutathione (GSH).

In both instances, when that happens, glutathione becomes oxidized (GSSG). Unlike GSH, GSSG destabilizes the CblC protein by causing a deleterious conformational change. That destabilization makes the already defective CblC even more defective, causing even more dysfunction in its handling of B12.

So a person with a CblC defect end ups with a lot of oxidative stress, not to mention excreting lots of their B12 stores as glutathionylcobalamin if they supplement with glutathione precursors.

There are a whole lot more questions than answers. Also, in reading I see they don't have a handle on how to treat this and have generally "poor" results with adult onset with their current nutritional treatment. I'd be dead if I were following their suggested treatment protocols. They haven't gotten their heads out of the HyCbl echo chamber that I can see and have no concept of methylfolate and they have botched the carnitine part and have no understanding of that yet.

It's clear from the literature that both cyanocobalamin and hyroxycobalamin are likely to be problematic for someone with an MMACHC problem. So you're definitely right, that doctors treating CblC deficiency who are not using MeCbl and AdCbl are not current on the research (and that's nearly all of them, apparently). It looks like the most "up to date" standard treatment for MMACHC may be OHCbl, betaine, folate and L-carnitine combined. So that would not seem ideal and is probably reflected in the poor response rate.

I would look at this differently. If you did find that you have an MMACHC problem, then you might be able to offer a good treatment where one doesn't currently exist, and potentially make a valuable contribution to science and medicine, since you've apparently found something very workable for yourself.

 

[Freddd]

With a defective CblC protein (caused by a defect in the MMACHC gene), then what would be happening is that that protein/enzyme (it's both a carrier and an enzyme) may not "hold" onto the B12 correctly, allowing it to be released inappropriately and/or inappropriately react with reduced glutathione (GSH).

In both instances, when that happens, glutathione becomes oxidized (GSSG). Unlike GSH, GSSG destabilizes the CblC protein by causing a deleterious conformational change. That destabilization makes the already defective CblC even more defective, causing even more dysfunction in its handling of B12.

So a person with a CblC defect end ups with a lot of oxidative stress, not to mention excreting lots of their B12 stores as glutathionylcobalamin if they supplement with glutathione precursors.


It's clear from the literature that both cyanocobalamin and hyroxycobalamin are likely to be problematic for someone with an MMACHC problem. So you're definitely right, that doctors treating CblC deficiency who are not using MeCbl and AdCbl are not current on the research (and that's nearly all of them, apparently). It looks like the most "up to date" standard treatment for MMACHC may be OHCbl, betaine, folate and L-carnitine combined. So that would not seem ideal and is probably reflected in the poor response rate.

I would look at this differently. If you did find that you have an MMACHC problem, then you might be able to offer a good treatment where one doesn't currently exist, and potentially make a valuable contribution to science and medicine, since you've apparently found something very workable for yourself.

Hi Nandixon,

Actually, working that out, from a questionnaire to detect it to the entire interactive responsive protocol has been what I have been working on for 11 years. I started this as a long term product development cycle, to save myself from a miserable "inevitable" deterioration and dying I just didn't know for sure what the name of the black box was that I was studying and reverse engineering. At the time I did massive reading none of these studies were available. It was like "3 known cases of adult survivors" in the CblC literature, obviously too rare and I wasn't seriously cognitively damaged or psychotic and it didn't seem likely. I jumped on the idea in the early 80s and was told by every doctor I went to that having that idea was obviously crazy in itself and I must be an alcoholic liar instead or have a serious case of "conversion disorder". Insisting that I couldn't utilize CyCbl well got me labeled as "It's All In Your Head". The folate distinction was impossible to make by A-B comparison until Metafolin came on the market.

Obviously they have missed a whole lot on working out a workable adult nutritional therapy, and for that matter, they treat children badly as well. They use folic acid for heavens sake and HyCbl and have no idea that different forms of carnitine make all the difference. Since the big mistake, identifying the protein mystery factor as CyCbl, and running with it despite it being a lab mistake and the real b12s identified in 1959, people like me have been under a slow death sentence. When Rich brought it up 6 years ago we both agreed that it was highly unlikely since most died in childhood and adult survivors were very damaged, especially cognitively. I raised the point that "rare" might mean "rarely recognized". Now I have to convince my new doc tomorrow before she destroys my working system. How's that for a cause of anxiety. A new doc is a terribly scary thing.

In reading these I have also seen the "pointer" to ALS. I hadn't seen how and where that fit in before.

 

[Freddd]

Oh what a relief it is. My appointment was a success. My new doc went through the case for adult onset CblC disease, and agrees. There were still two people in the office from when I walked in there almost 12 years ago as a one of the barely warmed over dead, and were able to describe how I changed in front of their eyes. She has an acceptable diagnosis that predicts EVERYTHING including the kidney damage and cardiomyopathy and the hell I've been through. She no longer wants a spinal draw because the SACD has a known and obvious cause and clearly does not need differentiation from MS. And she seemed amazed at how thoroughly I have it managed. I pointed out that my MCV/MCH now gives a measure of what percentage of the time I'm in folate deficiency. She will back me in the hospital, if that should happen, to make sure of the 3x10mg MeCbl injections and the Metafolin and potassium and other vitamins. This is the first time I haven't had to work through dozens of docs to find one that would back me on the vitamins and be willing to not upset my carefully balanced apple cart.

Now, will any of the testing and analysis services give MMACHC gene analysis? I need some advice from those who know their way around the testing and analysis scene.

 

[nandixon]

@Freddd
You'll need to have the entire gene sequenced, because there are so many (dozens) of potential defects in MMACHC. (They're apparently still finding new ones - especially relating to adult-onset cases.) 23andMe, for example, won't be helpful here.

We did something similar for my father (who had a defect in MSH2). We saw a genetics counselor and she helped with coordinating things. We ultimately used Mayo. It just required a simple blood sample that was mailed to them (no visit or traveling involved), and Medicare paid for it.

I'm not sure which facility would be best for MMACHC. There are several university-associated research groups working on CblC defects that would probably be happy to do it for free, too.

 

[Freddd]

@Freddd
You'll need to have the entire gene sequenced, because there are so many (dozens) of potential defects in MMACHC. (They're apparently still finding new ones - especially relating to adult-onset cases.) 23andMe, for example, won't be helpful here.

We did something similar for my father (who had a defect in MSH2). We saw a genetics counselor and she helped with coordinating things. We ultimately used Mayo. It just required a simple blood sample that was mailed to them (no visit or traveling involved), and Medicare paid for it.

I'm not sure which facility would be best for MMACHC. There are several university-associated research groups working on CblC defects that would probably be happy to do it for free, too.

Hi Nandixon,


We did something similar for my father (who had a defect in MSH2). We saw a genetics counselor and she helped with coordinating things. We ultimately used Mayo. It just required a simple blood sample that was mailed to them (no visit or traveling involved), and Medicare paid for it

How does one get Medicare to pay for it, perhaps especially since I am in a Medicare Complete program? For that matter how does one get referred to a genetics counselor. And for that matter, other than information what could they do for me? I already have my children on the right vitamins, so much better than the official "state of the art". My program takes care of the whole bit including the folate and potassium problems and at least one of my grandchildren needs at least the two B12s. If the whole family line were tested we would know for all of my grandchildren if they are sitting on a time bomb.

Perhaps the university approach would like to try 4 generations. My mother and half sisters might be interested. Her father had MS and B12 deficiency. Any bets where it comes from?

 

[nandixon]

@Freddd
It looks like Mayo does it:
http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/89436

So you might contact them for instructions for the appropriate requisition form (and consent for genetic testing) and mailer kit. Then have your doctor fill it out and have your blood drawn and mailed off.

One caveat Mayo notes is that they apparently don't test for large deletions in this gene (which is what my father had in MSH2). Perhaps that means that type of defect doesn't occur very frequently in MMACHC.(?)

 

[Helen]

@Freddd, congratulations to have found all your peaces to your puzzle.

Perhaps the university approach would like to try 4 generations. My mother and half sisters might be interested. Her father had MS and B12 deficiency.

I would try Professor Ruma Banerjee who is a renowned reseracher in the field of B12/redox. In a presentation, that I unfortunately can´t find at the moment, she told she was happy to e-mail with patients and answer their questions. As a researcher she appreciated to know that her findings could be of use for people. She will probably be interested in your findings and maybe include you in her research. Just an idea, you will probably get more. Best of luck!

 

[nandixon]

@Freddd
Actually, I had a second look, and Mayo might only be looking for known mutations on that gene. If that's correct, it may not be sufficient for you. Probably just have to contact them to be sure.