TEENAGE WEAKLING

Modified from Higgins et al. "Biochemistry for the Medical Sciences

In order to understand this case, students should be familiar with the material covered in the carbohydrate
metabolism lectures Signal transduction, enzyme regulation, Glycolysis, gluconeogenesis, glycogen
metabolism, glycogen storage disorders and regulation of blood glucose
Introduction
Skeletal muscle has a highly variable requirement for energy (in the form of ATP) depending on the demand
placed on the muscle. Potentially, this energy can be derived from a variety of sources. However, during severe
exercise when the energy demand is very high, blood is squeezed out of the muscle bed by contractile activity.
The muscle is then temporarily starved of oxygen (becomes ischemic), making oxidative processes very
difficult. In these circumstances, oxidation of fatty acids, normally the most efficient means of generating
energy, cannot be relied upon to satisfy the large energy demand. Instead the muscle has to depend more heavily
on anaerobic glycolysis. Even here the muscle faces problems since the diminished blood flow prevents glucose
being imported to fuel glycolysis so the muscles glycogen stores must be mobilized. In addition, the end
product of anaerobic glycolysis, lactate, cannot be removed efficiently via the blood and has to accumulate
within the muscle.
As a consequence, humans cannot carry out severe ischemic exercise for more than a few
minutes, as athletes will know only too well (Figure 1.1).
Comparatively rarely, individuals are encountered who, because of a genetic defect, cannot
tolerate ischemic exercise. This problem features such an individual.
The Problem
Phillip M., a 16-year-old boy, sought medical help for progressive muscle weakness over a
number of years. He experienced painful muscle cramps on severe exercise but he could
tolerate moderate exercise normally. The effect of severe ischemic exercise on blood lactate
is shown in Figure 1.2. Severe exercise was followed by dramatically elevated serum levels of lactate
dehydrogenase and creatine kinase-MM, which persisted for some hours after exercise had ceased. Phillip
also reported that his exercise intolerance became worse after he had eaten a meal rich in starch.
Myoglobinuria was also present and there was evidence of mild hemolysis. Phillips blood glucose level was
normal and could be elevated by treatment with glucagon, It was decided to do a muscle biopsy. Table 1.1
shows the results of the biopsy analysis.

Questions
1. Why is lactate, rather than pyruvate, produced by normal muscle when it is working anaerobically?
a During anaerobic respiration, the goal is to replenish the intracellular NAD+ to begin the cycle.
Lactate Dehydrogenase will increase NAD+ levels.
2. What do the results of the ischemic exercise test suggest is wrong with Phillips muscles?
a In Phils condition, there is a PFK1 deficiency, which leads to an accumulation of Glucose 6
phosphate. This leads to a condition where glycolysis isnt occurring, and thus, ATP production is
greatly reduced.
3. What is the normal effect of glucagon? What do the results of treating Phillip with glucagon indicate about
his condition?
a Glucagon works on the liver to help increase blood glucose levels. This normally occurs during the
fasting state (2-4 hours after a meal). When Phil was treated with glucagon, his blood glucose levels
increased, indicating that there arent any issues with glycogen breakdown or gluconeogenesis.
4. What can you conclude from the muscle biopsy analysis?
a There is a massive accumulation of Glucose 6 Phosphate in the tissue. This indicates that the PFK1
step isnt going through because of a PFK1 deficiency.
5. From your deductions so far, what do you think is the metabolic defect in the patient?
a I believe that he has Tauris Disease due to the deficiency in PFK1.
6. Why is Phillip able to tolerate moderate, but not severe, exercise?
a He is not completely deficient in PFK1, and can use other sources to increase the ATP levels. There
could be Fatty Acid Beta-Oxidation occurring, leading to NADH and FADH2 production. Moderate
levels of exercise were tolerable, indicating that some glycolysis was occurring.
7. What is the significance of his serum enzyme levels and the myoglobinemia?
a Every time he experiences cramping, there is a traumatic event and breakdown occurring in the
skeletal muscle. This would lead to an increased level of CK-MM.
8. Why is there an increased deposition of muscle glycogen (Table l.l)? Describe the normal glycogen
structure.
a There will be normal glycogen storage during the prandial state, but glycogen breakdown would be
inhibited due to the increased glucose 6 phosphate levels.
b Glycogen is a highly branched chain of Glucose molecules. Branches occur about every 8-10
residues in order to increase its carrying capacity.
9. What evidence may be present to support the suggestion of hemolysis? How does it arise in this patient?
a There is a lack of ATP which leads to muscle cramps
b The lack of ATP in RBC leads to hemolysis.
c There is no rise in serum lactate
d Bilirubin is a byproduct of Heme degredation, which would lead to the symptom of jaundice.

10. Name other enzyme deficiency disorders that can result in hemolysis. How do you differentiate between
hemolysis in these disorders? Identify the cause of hemolysis in each of these disorders.
a Hexokinase deficiency = same thing as pyruvate kinase deficiency. It is a nonspherocytic hemolytic
anemia. Cell membranes are weakened and irregular shape leads to lysis.
b Glucose 6 phosphate dehydrogenase = There will be a decrease in NADPH production here in the
pentose phosphate pathway. The reduction in NADPH leads to the inability to replenish the reduced
glutathione stores. This means that reactive oxygen species like peroxide cannot be adequately taken
care of => hemolysis.
c Pyruvate kinase = there will be back up of glycogen intermediates and a lack of ATP. Because ATP
isnt being produced, the RBCs will begin to die. Na+/K+ ATPase stops working, and K+ leaks out
leading to an intercellular hypotonic fluid. Water will follow the concentration gradient, and RBCs
will shrink and die.
11. What is the signal transduction pathway for the action of glucagon and insulin on the liver?
a Insulin hits the insulin receptor on the extracellular surface. The intracellular component of Tyrosine
Kinase then autophosphorylates, making it active. The activity causes GLUT-4 channel proteins to
be released and fused into the plasma membrane increasing glucose uptake by cells.
b Glucagon acts on the B-Adrenergic receptor. Upon binding, it activates Gs-alpha to become Gsalpha GTP. The dissociation of the subunit moves to activate Adenylyl Cyclase. This activity causes
in increase in cAMP, which then activates Protein Kinase A. This can then go and phosphorylate.

Further Questions
1. In what ways is the structure of glycogen abnormal in some other glycogen storage disorders?
a. In the Cori Disease, limit dextrinosis, or GSD Type III, there is a deficiency of glycogen
debranching enzyme. This means that when glycogenolysis is occurring, there will not be
complete breakdown of the glycogen stores. This will lead to decreased blood glucose levels.
b. In Andersons disease, or GSD Type IV, there is the absence of the glycogen branching enzyme.
This enzyme (amylo-1,4 -1,6 transglucosidase) is very important in the initial storage of glucose
as glycogen. This allows for the branching structure of glycogen. If this is deficient or absent, it
will lead to long unbranched chains of glycogen. These deposits then build up in the body
tissues, causing cirrhosis and death.
2. How is fructose 2,6 bisphosphate formed and what is its role in the liver? Describe feedforward and
feedback allosteric regulation of enzyme activity.
a. Fructose 2,6 bisphosphate is the result of PFK-2 activity. On the activation of PFK-2 by insulin,
there will be an increased level of F-2,6-Bisphosphate. This is an allosteric activator of PFK-1,
which is the main regulatory step of Glycolysis. This will concurrently inhibit gluconeogenesis.
3. Describe regulation of enzyme activity by covalent modification, induction and repression with examples for
each in carbohydrate metabolism.
a. Covalent modification: An example of this would be during the receptor mediated response of
glucagon. Here, the binding of the glucagon on the B-adrenergic receptor increased the
production of cAMP, and activation of PKA. PKA is then free to covalently modify
(phosphorylate) specific enzymes.
b. Induction: PDH complex with all 5 of its cofactors (FAD, NADH, CoA, Lipoic Acid, TPP)
c. Repression: This could be with inhibitors?
4. Indicate the biochemical defect in von Gierkes disease. Explain the reason for hypoglycemia, lactic acidosis,
hepatomegaly in children with von Gierkes disease.
a. Von Gierkes disease is due to a deficiency in glucose 6 phosphatase. This means that the liver,
and eventually kidneys, will not be able to increase blood glucose levels.
5. Prepare a clinical vignette for a child with a glycogen storage disorder.

a. A 14 year old, overweight male avoided physical activity all throughout childhood. He often
complained that exercise hurt, leading to generally sedentary habits. He was easily fatigued
and experienced muscle cramps in gym class during windsprints and other gym activities.
6. Name another glycogen storage disorder affecting the muscle. Indicate the enzyme deficiency in the disorder.
Why is hypoglycemia not a feature of this disorder?
a. Pompes disease, or GSD Type II, is a deficiency in lysosomal alpha 1-4 glucosidase. This leads
to normal glycogen synthesis/lysis in the cytosol, but not in the lysosomes that phagocytose it.
7. Recapitulate the reactions of glycogenolysis and glycogenesis. Explain how these pathways are reciprocally
regulated by glucagon, epinephrine and insulin. Identify the role of cAMP in glycogen metabolism.

a. Glycogenolysis

i. Breakdown of glycogen to G-1-P + free glucose + Pi

ii. G1P G6P glycolysis

b. Glycogenesis

i. Building of glycogen by adding UDP Glucose to an existing non reducing end