Late onset hyperornithinemia, hyperammonemia, and homocitrullinuria syndrome, presenting as recurrent metabolic encephalopathy, A case report

Introduction: and importance: Hyperornithinemia, hyperammonemia, and homocitrullinuria (HHH) syndrome
(OMIM 238970) seems to be an autosomal recessive disorder caused by a mitochondrial ornithine transporter 1
deficiency, which results in urea cycle dysfunction. HHH is the most uncommon of the urea cycle diseases, with
less than 100 cases recorded.
Case presentation: A previously healthy 29 year old male presented to the emergency department complaining of
decreased level of consciousness. CT scan, Cerebro-spinal-fluid analysis and toxicology screen were nonsignificant. Extended serum analysis showed elevated levels of ammonia. Urgent amino acid level analysis
showed elevated ornithine. Follow up genetic testing showed that the patient is homozygous for the mutation
c.44delG in exon 3 of SLC25A15 gene.
Clinical discussion: In this case, HHH syndrome presented as a late-onset metabolic encephalopathy. For diagnosis; elevated levels of ammonia, ornithine accompanied by the abovementioned genetic mutation confirms the
diagnosis. Treatment focuses on reduction of the ammonia levels using sodium benzoat, citrulline or arginine,
and low protein diet.
Conclusions: HHH syndrome, which is a urea cycle disorder, can present as a late-onset metabolic encephalopathy. High suspicion for genetic causes of metabolic encephalopathy should be maintained even for older patients without prior diagnosis in childhood/adolescence.