CREATINE REPLACEMENT THERAPY IN GUANIDINOACETATE METHYLTRANSFERASE DEFICIENCY, A NOVEL INBORN ERROR OF METABOLISM

Background The creatine/creatine-phosphate system is essential for the storage and transmission of phosphate-bound energy in muscle and brai n. In infants, inefficiency or failure of this metabolic pathway can i mpair the development of motor control and mentation. Methods We studi ed and treated an infant with extrapyramidal signs who was shown-by as say for urinary creatinine and by analysis of brain metabolites with u se of nuclear magnetic resonance spectra-to have depletion of body and brain creatine, due to inborn deficiency of guanidinoacetate methyltr ansferase (GAMT). Findings Long-term oral administration of creatine-m onohydrate (4-8 g per day) to this index patient resulted in substanti al clinical improvement, disappearance of magnetic resonance (MRI) sig nal abnormalities in the globus pallidus, and normalisation of slow ba ckground activity on the electroencephalogram (EEG). During the 25-mon th treatment period, both brain and total body creatine concentrations became normal. Interpretation Oral creatine replacement has proved to be effective in one child with an inborn error of GAMT. It may well b e effective in the treatment of other disorders of creatine synthesis.