Clinical case seminar - Insufficient ketone body use is the cause of ketotic Hypoglycemia in one of a pair of homozygotic twins

Context: Childhood ketotic hypoglycemia ( KH) is a disease characterized by fasting hypoglycemia and increased levels of ketone bodies. The cause is unknown. Objective: The objective of the study was to study a pair of homozygotic twin boys, one of whom had severe KH from the age of 14 months, whereas the other boy was apparently healthy. Design and Results: At the age of 6 yr, the boys were thoroughly investigated. During a 24-h fasting tolerance test, the twin with KH showed hypoglycemia ( blood glucose 2.0 mmol/liter) after 18 h. Three h before the occurrence of hypoglycemia, he had had 10 times higher beta-hydroxybutyrate levels than his brother, who showed no signs of hypoglycemia. Their glucose production rates were normal and similar ( 23.3 and 21.7 mu mol/ kg body weight per minute in the healthy and KH twin, respectively) as well as their lipolysis rates ( 5.8 and 6.8 mu mol/ kg body weight per minute, respectively). During repeated 60-min infusions of beta-hydroxybutyrate, the plasma level of beta-hydroxybutyrate increased 5-10 times more in the twin with KH ( mean 1.1 mmol/liter in the healthy and 10.8 mmol/ liter in the KH twin), indicating a disturbed clearance or metabolism of beta-hydroxybutyrate. No mutations were found in genes involved in ketone body metabolism or transport. Conclusion: In the affected boy, KH seems to be the result of a reduced capacity to use ketone bodies, leading to increased peripheral metabolism of glucose that cannot be met by hepatic glucose production. Because the boys are homozygotic twins and only one of them is affected, the ketotic hypoglycemia is most likely caused by an altered imprinting of gene(s) involved in regulating metabolic pathways