The term metabolism is derived from the Greek metabol, meaning "to change." It includes the broad array of chemical pathways that are necessary for normal development and homeostasis. In practice, clinicians generally use the term metabolism in reference to energy utilization for anabolism or catabolism. Alternatively, intermediary metabolism describes the myriad cellular pathways that convert energy sources from one form to another (e.g., citric acid cycle). The emerging field of metabolomics is based on the premise that the identification and measurement of metabolic products will enhance our understanding of physiology and disease.
Over the years, the classification of metabolic diseases has extended beyond traditional pathways involved in fuel metabolism to include disorders such as lysosomal storage diseases or connective tissue diseases. Thus, metabolic diseases really reflect disorders of cell biology. For example, lysosomal storage diseases (Chap. 361) result from a variety of defects, usually in a lysosomal enzyme, causing accumulation of a substrate within the lysosome. Certain lipodystrophies and cardiomyopathies can be caused by mutations in lamin A, a structural protein in the nuclear envelope. Membrane defects (Chap. 365), usually involving transporters of amino acids, sugars, or ions, cause disorders such as cystinuria, Hartnup's disease, or Wilson's disease. Connective tissue diseases (Chap. 363) frequently involve defects in collagen synthesis or structure (osteogenesis imperfecta, Ehlers-Danlos syndrome, Alport's syndrome) or in other extracellular matrix structural proteins such as fibrillin (Marfan syndrome). Many metabolic disorders originate from defects in enzymes involved in the synthesis or degradation of amino acids, carbohydrates, lipids, purines, or pyrimidines. (Chaps. 359, 362, 364). Lipoprotein disorders (Chap. 356) are caused by defects in a wide array of cellular pathways including membrane receptors (LDL-R), enzyme defects (lipoprotein lipase), carrier proteins (apoB100), or transporters (ABCA1). In some instances, metabolic abnormalities induce compensatory physiologic responses that reflect the interactions of multiple different metabolic pathways. For example, the metabolic syndrome (Chap. 242) includes a constellation of clinical features [central obesity, hypertriglyceridemia, low high-density lipoprotein (HDL) cholesterol, hyperglycemia, and hypertension]. It likely has multiple genetic and environmental origins. Cushing's syndrome reflects the metabolic effects of excess cortisol on multiple tissues (Chap. 342).
This broader definition results in a plethora of metabolic diseases, numbering in the thousands. Fortunately, comprehensive reference sources exist, such as the Online Metabolic and Molecular Bases of Inherited Disease (OMMBID): (http://genetics.accessmedicine.com/) and the Online Mendelian Inheritance in Man (OMIM): (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=OMIM). The study of metabolic diseases has been invaluable for advancing our understanding of human genetics by providing insight into principles such as patterns of inheritance, variable expressivity, phenotypic variation, and novel approaches to therapy, including screening programs, blood and organ transplantation, gene therapy, and enzyme replacement (Chap. 61).
This atlas provides a visual survey of selected metabolic disorders with references to the topics elsewhere in the text. The authors encourage submission of additional illustrations that might be used to facilitate learning among our peers and thereby enhance the recognition and care of patients with these disorders.
"Gauntlet" of pellagra (niacin deficiency). Indurated, lichenified, pigmented, and scaly skin on the dorsa of the hands. (Source: K Wolff, RA Johnson, D Suurmond: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005, www.accessmedicine.com.) See Chap. 74.
Scurvy (vitamin C deficiency). Perifollicular hemorrhage on the leg. The follicles are often plugged by keratin (perifollicular hyperkeratosis). This eruption occurred in a 46-year-old alcoholic, homeless male who also had bleeding gums and loose teeth. (Source: K Wolff, RA Johnson, D Suurmond: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005, www.accessmedicine.com.) Chap. 74.
Podagra with gouty inflammation of the first metatarsophalangeal (MTP) joint. Note the swelling and erythema of the left first MTP. (Courtesy of Kevin J. Knoop, MD, MS; with permission.) See Chaps. 333 and 359.
Gout. Large tophi of gout located in and around the right knee. (Courtesy of Daniel L. Savitt, MD; with permission.) See Chaps. 333 and 359.
Gout. The finger is an unusual site for gouty arthritis. Examination of the synovial fluid confirmed the diagnosis. (Courtesy of Alan B. Storrow, MD; with permission.)Chaps. 333 and 359.
Cushing's syndrome. Plethoric moon facies with erythema and telangiectases of cheek and forehead; the face and neck and supraclavicular areas (not depicted here) show increased deposition of fat. (Source: K Wolff, RA Johnson, D Suurmond: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005, www.accessmedicine.com.) See Chap. 342.
Necrobiosis lipoidica diabeticorum. A large, symmetric plaque with active tan-pink, well-demarcated, raised, firm borders and a yellow center in the pretibial regions of a 28-year-old diabetic female. The central parts of the lesions are depressed with atrophic changes of epidermal thinning and telangiectasis against yellow background. (Source: K Wolff, RA Johnson, D Suurmond: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 5th ed. New York, McGraw-Hill, 2005, www.accessmedicine.com.) See Chap. 344.
Patient with multiple endocrine neoplasia 2B ...
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