Dopamine beta-hydroxylase deficiency
General Information (adopted from Orphanet):
Synonyms, Signs: |
norepinephrine deficiency noradrenaline deficiency |
Number of Symptoms | 30 |
OrphanetNr: | 230 |
OMIM Id: |
223360
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ICD-10: |
G90.8 |
UMLs: |
C0342687 |
MeSH: |
C535600 |
MedDRA: |
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Snomed: |
237923004 |
Prevalence, inheritance and age of onset:
Prevalence: | 12 cases [Orphanet] |
Inheritance: |
Autosomal recessive [Orphanet] |
Age of onset: |
Neonatal Infancy [Orphanet] |
Disease classification (adopted from Orphanet):
Parent Diseases: |
Disorder of catecholamine synthesis
-Rare genetic disease Neurometabolic disease -Rare genetic disease -Rare neurologic disease Primary orthostatic hypotension -Rare neurologic disease Ptosis -Rare eye disease -Rare genetic disease |
Symptom Information:
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(HPO:0000855) | Insulin resistance | 27778639 | IBIS | 32 / 7739 | ||
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(HPO:0000842) | Hyperinsulinemia | 27778639 | IBIS | 39 / 7739 | ||
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(HPO:0011979) | Elevated urinary dopamine | Very frequent [IBIS] | 27778639 | IBIS | 2 / 7739 | |
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(HPO:0012099) | Abnormality of circulating catecholamine level | Very frequent [IBIS] | 27778639 | IBIS | 2 / 7739 | |
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(HPO:0000017) | Nocturia | 5 / 7739 | ||||
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(HPO:0000218) | High palate | 356 / 7739 | ||||
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(HPO:0000508) | Ptosis | 459 / 7739 | ||||
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(HPO:0001278) | Orthostatic hypotension | Very frequent [IBIS] | 27778639 | IBIS | 24 / 7739 | |
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(HPO:0001250) | Seizures | 1245 / 7739 | ||||
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(HPO:0005964) | Intermittent hypothermia | 2 / 7739 | ||||
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(HPO:0001998) | Neonatal hypoglycemia | 22 / 7739 | ||||
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(OMIM) | Decreased serum prolactin | 2 / 7739 | ||||
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(OMIM) | Impaired ejaculation due to impaired sympathetic activity | 1 / 7739 | ||||
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(HPO:0000007) | Autosomal recessive inheritance | 2538 / 7739 | ||||
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(HPO:0012877) | Retrograde ejaculation | 1 / 7739 | ||||
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(OMIM) | Increased plasma dihydroxyphenylacetic acid (DOPAC) | 1 / 7739 | ||||
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(OMIM) | Undetectable norepinephrine (noradrenaline) in plasma, urine, CSF | Very frequent [IBIS] | 27778639 | IBIS | 1 / 7739 | |
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(OMIM) | Hypothermia, episodic, in infants | 1 / 7739 | ||||
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(MedDRA:10038967) | Retrograde ejaculation | 1 / 7739 | ||||
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(OMIM) | Hypoglycemia, episodic, in infants | 1 / 7739 | ||||
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(OMIM) | Undetectable epinephrine (adrenaline) in plasma, urine, CSF | 1 / 7739 | ||||
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(OMIM) | Seizures may occur during hypotensive episodes | 1 / 7739 | ||||
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(OMIM) | Fainting spells | 1 / 7739 | ||||
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(OMIM) | Nasal stuffiness | 2 / 7739 | ||||
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(OMIM) | Orthostatic hypotension, severe, recurrent | 1 / 7739 | ||||
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(OMIM) | Delayed eye opening as a neonate (up to 2 weeks) | 1 / 7739 | ||||
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(OMIM) | Undetectable plasma DBH activity | 1 / 7739 | ||||
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(OMIM) | Undetectable dopamine beta-hydroxylase (DBH) protein in plasma, CSF, or sympathetic fibers | 1 / 7739 | ||||
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(OMIM) | Greatly increased dopamine in plasma, urine, CSF (approximately 10-fold increase) | 1 / 7739 | ||||
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(OMIM) | Stimulation of sympathetic fibers results in release of dopamine, not norepinephrine | 1 / 7739 |
Associated genes:
ClinVar (via SNiPA)
Gene symbol | Variation | Clinical significance | Reference |
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Additional Information:
Clinical Description OMIM |
Robertson et al. (1986) reported a 33-year-old woman of Scottish-Irish descent with isolated failure of autonomic noradrenergic neurotransmission caused by a defect in the beta-hydroxylation of dopamine in peripheral nerves. Clinical features included orthostatic hypotension, ptosis, nasal stuffiness, ... |
Molecular genetics OMIM | In 2 unrelated patients with dopamine beta-hydroxylase deficiency reported by Robertson et al. (1986) and Biaggioni et al. (1990), Kim et al. (2002) identified compound heterozygosity for mutations in the DBH gene (609312.0002-609312.0004). |
Diagnosis GeneReviews |
Physical examination of individuals with dopamine beta-hydroxylase (DBH) deficiency reveals the following [Vincent & Robertson 2002, Timmers et al 2004]:... DBHD 1Control 1Number: DBHD/ControlP ValueAge (years)27±14 | 34±100.091SA ratio1.3±0.231.4±0.217/860.338Valsalva phase IIDelta SBP (mm Hg)-40±27-7±226/550.001Delta HR (bpm)30±1130±166/530.971Valsalva phase IVDelta SBP (mm Hg)-22±1923±167/84<0.001Delta HR (bpm)7±8-8±117/82<0.001Valsalva ratio1.3±0.211.7±0.397/790.011HyperventilationDelta SBP (mm Hg)-13±13-7±128/860.148Delta HR (bpm)16±2011±117/860.308Cold pressorDelta SBP (mm Hg)5±1021±147/830.005Delta HR (bpm)16±1210±116/830.181HandgripDelta SBP (mm Hg)3±517±136/830.013Delta HR (bpm)15±1210±106/830.257EM Garland, unpublished data: Vanderbilt Autonomic Dysfunction CenterSA = sinus arrhythmiaSBP = systolic blood pressureHR = heart rate1. Mean ± SDPharmacologic tests of autonomic function. There is a several-fold hypersensitivity to α1-adrenoceptor agonists and β-adrenoceptor agonists:Propranolol, a β-adrenergic antagonist, does not lower heart rate.Intravenous atropine raises heart rate by 40-60 beats per minute.Pindolol, a β-adrenergic antagonist with some sympathomimetic activity, raises heart rate.Clonidine, a partial agonist of α2-adrenoceptors that acts centrally to reduce sympathetic outflow and lower blood pressure in normal individuals, can also exert peripheral pressor effects by stimulation of vascular α2-adrenoceptors. Individuals with DBH deficiency have no drop in seated mean arterial pressure following the administration of clonidine. On the contrary, significant increases in blood pressure are seen with higher doses of this agent.TestingDopamine beta-hydroxylase (EC 1.14.17.1) catalyzes the hydroxylation of dopamine (DA) to norepinephrine (NE). Although individuals with DBH deficiency lack plasma DBH activity and DBH immunoreactivity [Robertson et al 1986, Man in ‘t Veld et al 1987], the most helpful diagnostic test is measurement of the concentration of plasma norepinephrine (NE) and dopamine (DA). Plasma catecholamines. Biochemical features unique to DBH deficiency:Minimal or absent plasma NE and epinephrine AND a five- to tenfold elevation of plasma DA. This combination is probably pathognomonic of DBH deficiency. Plasma NE concentration should be below the limits of detection (<25 pg/mL or 0.15 nmol/L)Plasma DA concentration is frequently higher than 100pg/mL (0.65 nmol/L). Note: One unusual patient who was not diagnosed until age 73 years was reported to have a plasma dopamine concentration of 10,000 pg/mL (67 nmol/L) [Despas et al 2010]. Note: Although both baroreflex afferent and catecholamine release mechanisms are intact, DA is released in place of NE. Metabolites of NE including epinephrine, metanephrine, normetanephrine, vanillylmandelic acid (VMA), and dihydroxyphenylglycol (DHPG) are all very low or absent in plasma, urine, and CSF.Metabolites of DA including homovanillic acid (HVA) and 3-methoxytyramine are elevated [Robertson et al 1986, Man in ‘t Veld et al 1987].A more discriminating diagnostic measurement is the ratio of the DA metabolite dihydroxyphenylacetic acid (DOPAC) to dihydroxyphenylglycol (DHPG). In individuals with DBH deficiency, this ratio is at least 100:1 and may exceed 1000:1 (in healthy controls: <5:1). Note: (1) It is essential to assay both NE and DA with their metabolites and to use a procedure with high specificity for these catechols. (2) With some radioenzymatic methods for catecholamine determinations, a proportion of the DA may be erroneously measured as epinephrine [Robertson et al 1986]. The plasma DA concentration responds to various physiologic and pharmacologic stimuli as does NE in normal controls:Tyramine, for example, which normally is taken up by the NE transporter and stimulates NE release into the synapse, has no such effect in persons with DBH deficiency. NE remains undetectable after administration of high doses of tyramine, while DA increases [Robertson et al 1986]. This increase in plasma DA concentration probably reflects release of neuronal DA stores, but in some individuals, it may be the result of tyramine conversion to DA [Jacob et al 2003].A change from supine to upright posture doubles or triples the plasma DA concentration. This observation suggests that sympathetic nerves and reflex arcs are intact, but DA (rather than NE) is stored and released at the sympathetic synapse.Plasma DBH enzymatic assay. In addition to catalysis of DA, DBH catalyzes the hydroxylation of tyramine and other phenylethylamine derivatives. DBH is released into the synaptic cleft during vesicular exocytosis. A fraction of the DBH released into the synaptic cleft spills over into the blood, where it can be detected. Plasma levels of DBH enzyme activity vary over a wide range in different individuals, and most individuals with reduced plasma DBH enzyme activity do not have DBH deficiency. DBH enzyme activity is undetectable in the blood of individuals with DBH deficiency [Robertson et al 1986, Man in ‘t Veld et al 1987]. Assays for DBH enzymatic assay:A spectrophotometric procedure based on the enzymatic conversion of the substrate tyramine into the product octopamine in the presence of excess ascorbate, sodium fumarate, catalase, N-ethylmaleimide, and pargyline. The octopamine is then oxidized to p-hydroxybenzaldehyde. A two-step enzyme radioassay that incorporates conversion of phenylethylamine to phenylethanolamine by DBH, then metabolism of phenylethanolamine to N-methylphenylethanolamine by phenylethanolamine N-methyltransferase (PNMT) and radioactive S-adenosylmethionine. High-performance liquid chromatographic (HPLC) procedures. Plasma DBH immunoassay. This assay measures the total protein antigenically related to DBH, including inactive forms of the enzyme. Lack of DBH immunoreactivity in cerebrospinal fluid or plasma suggests that the cause of DBH deficiency is absent enzyme, rather than inactive enzyme.Immunocytochemical examination. DBH is located almost exclusively in the chromaffin granules of the adrenal medulla and in the large dense-core synaptic vesicles of both central and peripheral adrenergic and noradrenergic neurons. Immunocytochemical examination of these sympathetic fibers reveals undetectable DBH protein.Molecular Genetic TestingGene. DBH is the only gene in which mutations are known to cause DBH deficiency.Clinical testing Table 2. Summary of Molecular Genetic Testing Used in Dopamine Beta-Hydroxylase DeficiencyView in own windowGene SymbolTest MethodMutations DetectedMutation Detection Frequency 1Test AvailabilityDBHSequence analysisSequence variants 250%-100% 3Clinical1. The ability of the test method used to detect a mutation that is present in the indicated gene2. Examples of mutations detected by sequence analysis may include small intragenic deletions/insertions and missense, nonsense, and splice site mutations; typically, exonic or whole-gene deletions/duplications are not detected.3. Cho et al [2003] Interpretation of test results. For issues to consider in interpretation of sequence analysis results, click here.Information on specific allelic variants may be available in Molecular Genetics (see Table A. Genes and Databases and/or Pathologic allelic variants).Testing StrategyTo confirm/establish the diagnosis in a probandMeasurement of the plasma concentration of the catecholamines dopamine (DA) and norepinephrine (NE) and their metabolites, dihydroxyphenylglycol (DHPG) and dihydroxyphenylacetic acid (DOPAC) is the most helpful and least expensive diagnostic test. This analysis is commonly performed with a high performance liquid chromatography (HPLC) procedure and electrochemical detection. This should be the first test undertaken in individuals who describe life-long orthostatic hypotension and profound symptoms that inhibit the ability to stand. Undetectable norepinephrine and elevated dopamine would strongly suggest a diagnosis of DBH deficiency. Autonomic function testing that assesses sympathetic and parasympathetic control of heart rate and blood pressure should confirm the noradrenergic sympathetic failure and intact parasympathetic function of patients with DBH deficiency. A standard battery of tests includes sinus arrhythmia (heart rate response to 5-sec inhalation and 5-sec exhalation for 90 sec), a cold pressor test (hand in ice water for 1 min), isometric handgrip (30% of maximum voluntary contraction for 3 min), hyperventilation (approximately 60 breaths/min for 30 sec), and a Valsalva maneuver (40 mm Hg pressure generated for 15 seconds). The blunted sympathetic vasopressor response with the handgrip and cold pressor tests and the abnormal response with the Valsalva maneuver are evident in Table 1.DBH enzymatic assay and immunoassay are not necessary to confirm the diagnosis of DBH deficiency. It is important to realize that many apparently healthy individuals have very low DBH enzyme activity.Molecular genetic testing of DBH cannot be recommended at this time for confirming the diagnosis, since DBH deficiency is such a rare disorder and its genetic basis has not been elucidated in all affected individuals. However, molecular genetic testing may be useful to further clarify genotype-phenotype correlations. Carrier testing for at-risk relatives requires prior identification of the disease-causing mutations in the family.Note: Carriers are heterozygotes for this autosomal recessive disorder and are not at risk of developing the disorder.Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require prior identification of the disease-causing mutations in the family.Genetically Related (Allelic) DisordersSeveral normal allelic variants in DBH have been identified. Linkage and association studies with these variants have been conducted with mixed results in individuals with schizophrenia [Pal et al 2009], migraine [Fernandez et al 2009], attention deficit/hyperactivity disorder [Kopeckova et al 2006, Elia & Devoto 2007, Gizer et al 2009], Parkinson disease [Ross et al 2008], addictive behavior [Freire et al 2006, Köhnke et al 2006, Guindalini et al 2008], and depression [Togsverd et al 2008]. In addition, promoter variants associated with lower plasma DBH activity predict lower blood pressure [Chen et al 2010, Chen et al 2011].
Clinical Description GeneReviews | Dopamine beta-hydroxylase (DBH) deficiency is characterized by a lack of sympathetic noradrenergic function but normal parasympathetic and sympathetic cholinergic function. Affected individuals exhibit profound deficits in autonomic regulation of cardiovascular function, but apparently only subtle signs of central nervous system dysfunction [Robertson et al 1986, Man in ‘t Veld et al 1987, Timmers et al 2004].... Feature# of Individuals 1Severe orthostatic hypotension | 18/18 (100%)Anemia8/13 (61%)Ptosis of eyelids11/12 (92%)Abnormal sexual maturation0/11Hyperflexible or hypermobile joints6/9 (67%)ECG abnormalities 22/11 (18%)Epileptiform symptoms4/11 (36%)Nasal stuffiness9/9 (100%)Hypoglycemia3/10 (30%)Sluggish deep-tendon reflexes3/8 (38%)Increased plasma creatinine4/9 (44%)Polyuria/nocturia3/8 (38%)High palate9/9 (100%)Increased BUN5/8 (63%)Muscle hypotonia3/8 (38%)Postprandial hypotension3/7 (43%)Sleep irregularities5/6 (83%)Impaired ejaculation4/4 (100%)1. Number of individuals with the finding/total number evaluated for the finding2. ECG=electrocardiogramPresyncopal symptoms include dizziness, blurred vision, dyspnea, nuchal discomfort, and occasionally chest pain. Symptoms may worsen in hot environments or after heavy meals or alcohol ingestion. Occasional bouts of unexplained diarrhea occur.Elevated blood urea nitrogen has been noted in five affected individuals in the United States [Garland et al 2005a, Garland et al 2009]. This may be evidence of a loss of renal function. The estimated GFR of a 57-year-old affected female was reduced to 18 mL/min/1.73 m2.Despite the lack of norepinephrine, persons with DBH deficiency apparently have relatively normal mental status. Five affected individuals and ten matched healthy unaffected participants underwent a comprehensive battery of neurocognitive testing in addition to brain MRI, pupillometry and EEG. Performance of the affected individuals, whether on or off droxidopa treatment, was similar to that of the unaffected individuals in most aspects, suggesting that other systems compensate for absent norepinephrine in affected individuals. Brain MRI studies revealed a smaller total brain volume in the affected individuals compared to unaffected individuals, although relative proportions of white and gray matter and cerebrospinal fluid were similar between the two groups. In addition, affected individuals had a temporal-attention deficit when they were not on treatment. During an attentional-blink task, participants were asked to identify two digits, separated by a variable number of letters. Attentional blink refers to the deficit in processing the second digit when it is presented within 200-400 msec of the first. Accuracy in identifying the second digit was impaired in affected individuals not on treatment but performance improved with droxidopa treatment [Jepma et al 2011]. Atrial fibrillation developed in one individual. Another individual had reduced T-wave amplitude, which may reflect an electrolyte abnormality [Man in ‘t Veld et al 1987].Olfactory function is relatively unaffected in individuals with DBH deficiency, who have intact noradrenergic neurons, in contrast to the marked deficit in individuals with pure autonomic failure who have peripheral neuronal degeneration [Garland et al 2011]. A 2010 case report described an individual with DBH deficiency who (in addition to features characteristic of this disorder) also had bilateral colobomas, short hands, and high-arched feet. The investigators found a mosaic deletion on chromosome 11p13 that includes the gene PAX6 [Erez et al 2010].Because so few individuals have been diagnosed with DBH deficiency, it is not known what relationship the less common findings have to the absence of DBH or elevated levels of dopamine; they may be fortuitous findings. However, the investigators [Man in ‘t Veld et al 1987] speculated that hypoglycemia may result from adrenomedullary failure and the T-wave abnormalities from failure of noradrenergic control. Since dopamine inhibits both the synthesis and secretion of prolactin, some degree of hypoprolactemia is not surprising in these individuals.Four persons with DBH deficiency have died. Three died from natural causes at ages 28, 57, and 63 years. One died at age 20 years, possibly by suicide. Autopsy of the 28-year old male reported “scattered pyknotic cerebral neurons, isolated microfoci of cortical gliosis, cardiac arteriolar smooth muscle hypertrophy, scattered fibrosis in the cardiac conduction system, and sclerotic renal glomeruli” [Cheshire et al 2006]. In addition, DBH immunostaining was absent in neurons of the ventrolateral medulla.
Genotype-Phenotype Correlations GeneReviews | Because of the small number of individuals diagnosed with DBH deficiency, it is not possible to determine correlations between specific phenotypes and mutations in DBH.... |
Differential Diagnosis GeneReviews | The striking catecholamine abnormalities distinguish DBH deficiency from other disorders. Other catecholamine disorders, such as aromatic amino acid decarboxylase deficiency, have clinical presentations distinct from that of DBH deficiency [Swoboda et al 2003].... |
Management GeneReviews | To determine the extent of functional disturbance in an individual diagnosed with dopamine beta-hydroxylase (DBH) deficiency, the following are indicated:... |
Molecular genetics GeneReviews |
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.... Gene SymbolChromosomal LocusProtein NameLocus SpecificHGMDDBH9q34 | Dopamine beta-hydroxylaseDBH homepage - Mendelian genesDBHData are compiled from the following standard references: gene symbol from HGNC; chromosomal locus, locus name, critical region, complementation group from OMIM; protein name from UniProt. For a description of databases (Locus Specific, HGMD) to which links are provided, click here.Table B. OMIM Entries for Dopamine Beta-Hydroxylase Deficiency (View All in OMIM) View in own window 223360DOPAMINE BETA-HYDROXYLASE DEFICIENCY, CONGENITAL 609312DOPAMINE BETA-HYDROXYLASE, PLASMA; DBHNormal allelic variants. DBH is approximately 23 kb and is composed of 12 exons. Linkage of DBH to the ABO blood group locus on chromosome 9 has been demonstrated. Normal allelic variants of DBH correlate with variation in the level of DBH activity in individuals who are neither affected nor carriers. A polymorphism in the promoter region contributes up to 52% of the variation (see Normal gene product).Pathologic allelic variants. The four putative disease mutations first identified by Kim et al [2002] in two patients with DBH deficiency have not been reported in other autonomic disorders [Cho et al 2003]. Affected individual #1 was a compound heterozygote for c.[348+2T>C];[342C>A]. Affected individual #2 had one allele with c.348+2T>C and a second allele with two missense variants c.[301G>A;1033G>A]. A third compound heterozygote was more recently identified: c.[348+2T>C];[c.1085C>A] [Kim et al 2011].The c.348+2T>C mutation and three additional mutations in exons 3, 4, and 11 have been identified in four families with DBH deficiency in the Netherlands [Deinum et al 2004]. The affected individuals were a c.348+2T>C homozygote, a c.806G>T homozygote, and a compound heterozygote for c.[348+2T>C];[617delA].Table 4. Selected DBH Allelic VariantsView in own windowClass of Variant AlleleDNA Nucleotide Change