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Late-onset multiple acyl-CoA dehydrogenase deficiency: an insidious presentation
  1. Naini Nishita Rao1,2,
  2. Kharis Burns1,2,
  3. Catherine Manolikos1,3 and
  4. Samantha Hodge1,3
  1. 1Department of Endocrinology and Diabetes, Royal Perth Hospital, Perth, Western Australia, Australia
  2. 2School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
  3. 3Department of Dietetics and Nutrition, Royal Perth Hospital, Perth, Western Australia, Australia
  1. Correspondence to Dr Naini Nishita Rao; n.nishita.rao{at}


Multiple acyl-CoA dehydrogenase deficiency (MADD) is a rare inborn error of metabolism that results in impairment of mitochondrial β-oxidation of fatty acids. It is inherited in an autosomal recessive manner and impairs electron transfer in the electron transport chain. The clinical manifestations of MADD are highly variable and include exercise intolerance, myopathy, cardiomyopathy, encephalopathy, coma and death. Early-onset MADD is often associated with a high mortality with significant number of patients presenting with severe metabolic acidosis, non-ketotic hypoglycaemia and/or hyperammonaemic presentations. While late-onset MADD is suggested to have a lower mortality, the severe encephalopathic presentations may well be under-reported as a diagnosis of MADD may not be considered.

MADD is treatable with riboflavin and appropriate nutrition with a focus on prevention and early management of metabolic decompensation. The neonatal phenotype differs significantly from late-onset MADD, where diagnosis may be delayed due to heterogeneity in clinical features, atypical presentation and confounding comorbidities, together with lower awareness among physicians.

This report describes a woman in her 30s who presented with acute-onset ataxia, confusion and hyperammonaemic encephalopathy requiring intubation. Subsequent biochemical investigation revealed a diagnosis of MADD. At present, there are no national guidelines in Australia for the management of MADD. This case highlights the investigation and treatment of late-onset MADD.

  • endocrinology
  • metabolic disorders
  • lipid disorders

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  • Contributors NNR, who is responsible for the overall content as guarantor, was involved in the planning and data collection for the report. Both NNR and KB collaboratively were involved in the reporting of the article. SH and CM were the primary dieticians involved in the care of the patient with KB being the primary physician in charge. SH and CM were involved in the critical revision and editing of the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.