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SUCLA2-Related Mitochondrial DNA Depletion Syndrome, Encephalomyopathic Form with Methylmalonic Aciduria

Synonym: SUCLA2 Deficiency


Author Information and Affiliations

Initial Posting: ; Last Revision: May 18, 2017.

Estimated reading time: 14 minutes


Clinical characteristics.

SUCLA2-related mitochondrial DNA (mtDNA) depletion syndrome, encephalomyopathic form with methylmalonic aciduria is characterized by onset of the following features in infancy or childhood (median age of onset 2 months; range of onset birth to 6 years): psychomotor retardation, hypotonia, dystonia, muscular atrophy, sensorineural hearing impairment, postnatal growth retardation, and feeding difficulties. Other less frequent features include distinctive facial features, contractures, kyphoscoliosis, gastroesophageal reflux, ptosis, choreoathetosis, ophthalmoplegia, and epilepsy (infantile spasms or generalized convulsions). The median survival is 20 years; approximately 30% of affected individuals succumb during childhood. Affected individuals may have hyperintensities in the basal ganglia, cerebral atrophy, and leukoencephalopathy on head MRI. Elevation of methylmalonic acid (MMA) in the urine and plasma is found in a vast majority of affected individuals, although at levels that are far below those typically seen in individuals with classic methylmalonic aciduria.


The diagnosis of SUCLA2-related mtDNA depletion syndrome is established in a proband by the identification of biallelic pathogenic variants in SUCLA2 on molecular genetic testing.


Treatment of manifestations: Physical therapy to maintain muscle function and prevent joint contractures; anti-seizure medication for epileptic seizures; nasogastric or gastrostomy tube as needed to assure adequate caloric intake; chest physiotherapy, aggressive antibiotic treatment of chest infections, and respiratory aids such as assisted nasal ventilation or use of a tracheostomy and ventilator when indicated; bracing to treat scoliosis or kyphosis; blepharoplasty for significant ptosis; and hearing aids/cochlear implantation for sensorineural hearing loss.

Surveillance: Routine monitoring of development, growth, and hearing; periodic ophthalmologic evaluations; routine skeletal evaluations for kyphoscoliosis and joint contractures.

Genetic counseling.

SUCLA2-related mtDNA depletion syndrome is inherited in an autosomal recessive manner. At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected and not a carrier. Carrier testing for at-risk relatives and prenatal testing for pregnancies at increased risk are possible once the pathogenic variants in the family have been identified.


Suggestive Findings

SUCLA2-related mitochondrial DNA (mtDNA) depletion syndrome, encephalomyopathic form with methylmalonic aciduria typically manifests during early infancy and should be suspected in individuals with a combination of the following clinical, brain MRI, and supportive laboratory and muscle biopsy findings.

Clinical features

  • Psychomotor retardation
  • Hypotonia
  • Sensorineural hearing impairment
  • Dystonia
  • Feeding difficulties
  • Growth retardation / failure to thrive
  • Muscular atrophy

Brain MRI findings

  • Basal ganglia hyperintensities
  • Cerebral atrophy
  • Leukoencephalopathy

Supportive laboratory findings

  • Urine organic acid analysis
    • Elevation of methylmalonic acid (MMA) in the vast majority of affected children. However, the MMA level is considerably less pronounced than in classic methylmalonic aciduria and can be only marginally elevated or even normal on rare occasions [Lamperti et al 2012].
    • Several other metabolites may be elevated in urine, including methylcitrate, 3-methylglutaconic acid, 3-hydroxyisovaleric acid, and Krebs cycle intermediates such as succinate, fumarate, and 2-ketoglutarate [Carrozzo et al 2016].
  • Plasma MMA level
    • Elevation has been reported in all affected individuals analyzed, including those with marginally elevated urine MMA level [Carrozzo et al 2016].
    • Plasma MMA level may be more sensitive in identifying SUCLA2-related mtDNA depletion syndrome than urine organic acid analysis.
  • Acylcarnitine profile. Elevated C3; thus, this condition can potentially be detected by newborn screening.
  • Plasma and CSF lactate levels. Elevated in most affected individuals

Muscle biopsy findings

  • Increased fiber size variability, atrophic fibers, intracellular lipid accumulation, and COX-deficient fibers
    Approximately 20% of affected individuals will have normal muscle histology [Carrozzo et al 2016].
  • In some cases, structurally altered mitochondria with abnormal cristae on electron microscopy
  • In the majority of individuals, abnormal electron transport chain activity
    • The most common abnormalities are combined complex I and IV deficiencies, combined complex I, III, and IV deficiencies, and isolated complex IV deficiency.
    • Electron transport chain activity has been reported to be normal in approximately 10% of affected individuals who underwent this test [Carrozzo et al 2016].
  • Mitochondrial DNA content in muscle tissue of affected individuals typically reduced to 20%-60% of tissue- and age-matched controls [Elpeleg et al 2005, Carrozzo et al 2007, Ostergaard et al 2007, Carrozzo et al 2016]

Establishing the Diagnosis

The diagnosis of SUCLA2-related mtDNA depletion syndrome is established in a proband by the identification of biallelic pathogenic variants in SUCLA2 on molecular genetic testing (see Table 1).

Molecular genetic testing approaches can include single-gene testing, use of a multigene panel, and more comprehensive genomic testing:

  • Single-gene testing. Sequence analysis of SUCLA2 is performed first and followed by gene-targeted deletion/duplication analysis if only one or no pathogenic variant is found.
    Note: Targeted analysis for the c.534+1G>A pathogenic founder variant can be performed first in individuals of Faroese ancestry (see Prevalence).
  • A multigene panel that includes SUCLA2 and other genes of interest (see Differential Diagnosis) may also be considered. Note: (1) The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and are likely to change over time. (2) Some multigene panels may include genes not associated with the condition discussed in this GeneReview; thus, clinicians need to determine which multigene panel is most likely to identify the genetic cause of the condition while limiting identification of variants of uncertain significance and pathogenic variants in genes that do not explain the underlying phenotype. (3) Methods used in a panel may include sequence analysis, deletion/duplication analysis, and/or other non-sequencing-based tests.
    For an introduction to multigene panels click here. More detailed information for clinicians ordering genetic tests can be found here.
  • More comprehensive genomic testing (when available) including exome sequencing, mitochondrial sequencing, and genome sequencing may be considered if single-gene testing (and/or use of a multigene panel that includes SUCLA2) fails to confirm a diagnosis in an individual with features of SUCLA2-related mtDNA depletion syndrome. Such testing may provide or suggest a diagnosis not previously considered (e.g., mutation of a different gene or genes that results in a similar clinical presentation).
    For an introduction to comprehensive genomic testing click here. More detailed information for clinicians ordering genomic testing can be found here.

Table 1.

Molecular Genetic Testing Used in SUCLA2-Related Mitochondrial DNA Depletion Syndrome, Encephalomyopathic Form with Methylmalonic Aciduria

Gene 1MethodProportion of Probands with Pathogenic Variants 2 Detectable by Method
SUCLA2 Sequence analysis 346/50 4
Gene-targeted deletion/duplication analysis 54/50 4

See Molecular Genetics for information on allelic variants detected in this gene.


Sequence analysis detects variants that are benign, likely benign, of uncertain significance, likely pathogenic, or pathogenic. Variants may include small intragenic deletions/insertions and missense, nonsense, and splice-site variants; typically, exon or whole-gene deletions/duplications are not detected. For issues to consider in interpretation of sequence analysis results, click here.


Gene-targeted deletion/duplication analysis detects intragenic deletions or duplications. Methods used may include a range of techniques such as quantitative PCR, long-range PCR, multiplex ligation-dependent probe amplification (MLPA), and a gene-targeted microarray designed to detect single-exon deletions or duplications.

Clinical Characteristics

Clinical Description

To date 50 individuals with SUCLA2-related mtDNA depletion syndrome have been reported [Elpeleg et al 2005, Carrozzo et al 2007, Ostergaard et al 2007, Morava et al 2009, Lamperti et al 2012, Navarro-Sastre et al 2012, Jaberi et al 2013, Matilainen et al 2015, Nogueira et al 2015, Carrozzo et al 2016]. The clinical description here is based on what has been reported in these 50 individuals. The common clinical manifestations are summarized in Table 2 [Carrozzo et al 2016].

Table 2.

Common Clinical Manifestations of SUCLA2-Related Mitochondrial DNA Depletion Syndrome, Encephalomyopathic Form with Methylmalonic Aciduria

  • Dystonia
  • Hypotonia
  • Psychomotor retardation
  • Sensorineural hearing impairment
  • Feeding difficulties
  • Growth retardation / failure to thrive
  • Muscular atrophy
  • Choreoathetosis
  • Distinctive facial features incl brachycephaly, epicanthus, upslanted palpebral fissures
  • Epilepsy
  • Gastroesophageal reflux disease
  • Hyperhidrosis
  • Hypertonia
  • Hypoglycemia
  • Joint contractures
  • Kyphoscoliosis
  • Ophthalmoplegia
  • Ptosis
  • Strabismus
  • Recurrent respiratory infections
  • Recurrent vomiting
  • Respiratory distress

Affected children with SUCLA2-related mtDNA depletion syndrome typically have an uncomplicated prenatal course and birth. Birth weight and birth length are typically within the normal range. The median age of onset of manifestations is two months, with a range from birth to six years [Carrozzo et al 2016].

Neurocognitive. The vast majority of affected children present during infancy with hypotonia and psychomotor retardation. Dystonia and muscle atrophy also occur commonly. Other, less frequent, neurologic manifestations include hypertonia, choreoathetosis, ptosis, ophthalmoplegia, strabismus, and epilepsy (including infantile spasms and generalized convulsions). Brain MRI typically shows basal ganglia hyperintensities (70%), cerebral atrophy (70%), and leukoencephalopathy (15%) [Carrozzo et al 2016].

Hearing. Most affected children develop sensorineural hearing impairment; some benefit from a cochlear implant.

Growth. Postnatal growth retardation with low weight and length/height is a common feature of this condition. Feeding difficulties, often necessitating tube feeding, occur commonly, while recurrent vomiting and gastroesophageal reflux disease occasionally occur. The feeding difficulties, recurrent vomiting, and gastroesophageal reflux disease can lead or contribute to failure to thrive in affected infants.

Distinctive facial features including brachycephaly, epicanthus, and upslanted palpebral fissures, have been reported.

Respiratory. Recurrent respiratory infections occur occasionally. Respiratory distress due to muscle weakness, obstructive sleep apnea, tracheomalacia, and abnormal breathing has also been reported.

Skeletal. Progressive kyphoscoliosis has been reported occasionally and may require treatment. Joint contractures can develop in extremities secondary to decreased movement.

Other. Hyperhidrosis and neonatal hypoglycemia have occasionally been reported. Other rare manifestations:

  • Anemia
  • Acquired dislocation of hip and shoulder
  • Irritability
  • Sleep disturbance

Life span is shortened, with median survival of 20 years in individuals with SUCLA2-related mtDNA depletion syndrome. Approximately 30% of affected individuals reportedly died during childhood [Carrozzo et al 2016].

Genotype-Phenotype Correlations

Pathogenic missense variants can result in some residual enzyme activity, and hence a milder phenotype. Survival in affected individuals with biallelic pathogenic missense variants was significantly longer than in those with biallelic loss-of-function variants (deletions, frameshift and nonsense variants) (median survival age 21 years vs 15 years) [Carrozzo et al 2016].


SUCLA2-related mtDNA depletion syndrome is rare; the exact prevalence is unknown. To date, 50 individuals of different ethnic origins have been reported [Elpeleg et al 2005, Carrozzo et al 2007, Ostergaard et al 2007, Morava et al 2009, Lamperti et al 2012, Navarro-Sastre et al 2012, Jaberi et al 2013, Matilainen et al 2015, Nogueira et al 2015, Carrozzo et al 2016].

A founder pathogenic variant in families of Faroese origin has been identified (Table 4); the disorder has a high incidence (1:1,700) and a carrier frequency of 1:33 in the Faroe Islands [Ostergaard et al 2007].

Differential Diagnosis

SUCLA2-related mtDNA depletion syndrome needs to be differentiated from other mtDNA depletion syndromes, a genetically and clinically heterogeneous group of autosomal recessive disorders that are characterized by a severe reduction in mtDNA content leading to impaired energy production in affected tissues and organs.

Mitochondrial DNA depletion syndromes occur as a result of defects in mtDNA maintenance caused by pathogenic variants in nuclear genes that function in either mitochondrial nucleotide synthesis (e.g., TK2, SUCLA2, SUCLG1, RRM2B, DGUOK, and TYMP) or mtDNA replication (e.g., POLG and TWNK).

Mitochondrial DNA depletion syndromes are phenotypically classified into myopathic, encephalomyopathic, hepatocerebral, and neurogastrointestinal forms (Table 3) [El-Hattab & Scaglia 2013].

Myopathic forms present in infancy or early childhood with hypotonia, proximal muscle weakness, and feeding difficulty. Cognition is usually spared. Typically, there is rapid progression of muscle weakness with respiratory failure and death within a few years of onset.

Encephalomyopathic mtDNA depletion syndromes present in infancy with hypotonia and global developmental delay. Depending on the underlying defect, other features, including deafness, movement disorders, Leigh-like syndrome, and renal disease, can be observed.

Hepatocerebral forms present with early-onset liver dysfunction and neurologic involvement, including developmental delay, abnormal eye movements, and peripheral neuropathy.

Neurogastrointestinal forms, the prototype of which is mitochondrial neurogastrointestinal encephalopathy (MNGIE) disease, present in adolescence to early adulthood with progressive gastrointestinal dysmotility, cachexia, and peripheral neuropathy.

The phenotype of SUCLG1-related mtDNA depletion syndrome may be difficult to distinguish from SUCLA2-related mtDNA depletion. SUCLG1-related mtDNA depletion syndrome is characterized by psychomotor retardation, hypotonia, muscle atrophy, feeding difficulties, growth retardation, dystonia, hearing loss, lactic acidosis, elevated urine and plasma MMA, and mtDNA depletion. However, hepatopathy and cardiomyopathy occur in SUCLG1-related mtDNA depletion only [Carrozzo et al 2016].

Table 3.

Mitochondrial DNA Depletion Syndromes

Phenotype 1GeneMitochondrial DNA Depletion Syndrome #, TypeReference 2
Hepatocerebral DGUOK 3, hepatocerebral type Deoxyguanosine Kinase Deficiency
POLG 4A, Alpers type POLG-Related Disorders
MPV17 6, hepatocerebral type MPV17-Related Hepatocerebral Mitochondrial DNA Depletion Syndrome
7, hepatocerebral typeOMIM 271245
TFAM 15, hepatocerebral typeOMIM 617156
SUCLA2 5, encephalomyopathic type w/methylmalonic aciduriaSUCLA2-Related Mitochondrial DNA Depletion Syndrome, Encephalomyopathic Form with Methylmalonic Aciduria
FBXL4 13, encephalomyopathic type FBXL4-Related Encephalomyopathic Mitochondrial DNA Depletion Syndrome
SUCLG1 9, encephalomyopathic type with methylmalonic aciduria SUCLG1-Related mtDNA Depletion Syndrome, Encephalomyopathic Form with Methylmalonic Aciduria
RRM2B 8A, encephalomyopathic type w/renal tubulopathy RRM2B-Related Mitochondrial Disease
OPA1 14, encephalocardiomyopathic typeOMIM 616896
ABAT Encephalomyopathic typeOMIM 613163
TYMP 1, MNGIE type Mitochondrial Neurogastrointestinal Encephalopathy Disease
POLG 4B, MNGIE type POLG-Related Disorders
RRM2B 8B, MNGIE type RRM2B-Related Mitochondrial Disease
Myopathic TK2 2, myopathic type TK2-Related Mitochondrial DNA Depletion Syndrome, Myopathic Form
AGK 10, cardiomyopathic type (Sengers syndrome)OMIM 212350
MGME1 11, myopathic typeOMIM 615084
SLC25A4 12B, cardiomyopathic typeOMIM 615418

Within each phenotypic category, mtDNA depletion syndromes are ordered by relative prevalence.


See hyperlinked GeneReview or OMIM phenotype entry for more information.


Evaluations Following Initial Diagnosis

To establish the extent of disease and needs in an individual diagnosed with SUCLA2-related mtDNA depletion syndrome, the following evaluations need to be performed (if not already done as part of the initial diagnostic evaluation):

  • Comprehensive neurologic examination and developmental/cognitive assessment. The following diagnostic modalities can be used to assess the degree of neurologic involvement:
    • Neuroimaging (preferably brain MRI) to establish the degree of central nervous system involvement
    • EMG to assess myopathy
    • EEG if seizures are suspected
  • Audiologic evaluation
  • Ophthalmologic examination
  • Nutritional evaluation and swallowing assessment for feeding difficulties and growth failure
  • Physical examination for the back and joints for kyphoscoliosis and joint contractures
  • Consultation with a clinical geneticist and/or genetic counselor

Treatment of Manifestations

Management should involve a multidisciplinary team including specialists in neurology, audiology, child development, gastroenterology, nutrition, and clinical genetics. Treatments include the following:

  • Physical therapy to help maintain muscle function and prevent joint contractures
  • Standard treatment with anti-seizure medication for seizures
  • Nutritional support by a dietitian and the use of a nasogastric tube or gastrostomy tube feedings to address feeding difficulties and failure to thrive
  • Chest physiotherapy, aggressive antibiotic treatment of chest infections, and artificial ventilation (including assisted nasal ventilation or intubation and the use of a tracheostomy and ventilator) for respiratory insufficiency
  • Bracing for scoliosis and kyphosis
  • Blepharoplasty for significant ptosis
  • Hearing aids and/or cochlear implantation for sensorineural hearing loss


No clinical guidelines for surveillance are available. The following evaluations are suggested, with frequency varying according to the severity of the condition:

  • Routine developmental and neurologic assessment
  • Periodic nutritional and growth assessment
  • Periodic hearing evaluation
  • Periodic ophthalmologic examination
  • Routine physical examination of back and joints for kyphoscoliosis and joint contractures

Evaluation of Relatives at Risk

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Therapies Under Investigation

Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.

Genetic Counseling

Genetic counseling is the process of providing individuals and families with information on the nature, mode(s) of inheritance, and implications of genetic disorders to help them make informed medical and personal decisions. The following section deals with genetic risk assessment and the use of family history and genetic testing to clarify genetic status for family members; it is not meant to address all personal, cultural, or ethical issues that may arise or to substitute for consultation with a genetics professional. —ED.

Mode of Inheritance

SUCLA2-related mitochondrial DNA depletion syndrome, encephalomyopathic form with methylmalonic aciduria is inherited in an autosomal recessive manner.

Risk to Family Members

Parents of a proband

  • The parents of an affected child are obligate heterozygotes (i.e., carriers of one SUCLA2 pathogenic variant).
  • Heterozygotes (carriers) are asymptomatic and are not at risk of developing the disorder.

Sibs of a proband

  • At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected and not a carrier.
  • Heterozygotes (carriers) are asymptomatic and are not at risk of developing the disorder.

Offspring of a proband. Individuals with SUCLA2-related mtDNA depletion syndrome are not reported to reproduce.

Other family members. Each sib of the proband's parents is at a 50% risk of being a carrier of a SUCLA2 pathogenic variant.

Carrier Detection

Carrier testing for at-risk relatives requires prior identification of the SUCLA2 pathogenic variants in the family.

In populations with a high carrier rate and/or a high rate of consanguinity, the reproductive partner of the proband may be a carrier. Thus, the risk to offspring is most accurately determined after molecular genetic testing of the proband's reproductive partner.

Related Genetic Counseling Issues

Family planning

  • The optimal time for determination of genetic risk, clarification of carrier status, and discussion of the availability of prenatal/preimplantation genetic testing is before pregnancy.
  • It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are carriers or are at risk of being carriers.

DNA banking. Because it is likely that testing methodology and our understanding of genes, pathogenic mechanisms, and diseases will improve in the future, consideration should be given to banking DNA from probands in whom a molecular diagnosis as not been confirmed (i.e., the causative pathogenic mechanism is unknown).

Prenatal Testing and Preimplantation Genetic Testing

Once the SUCLA2 pathogenic variants have been identified in an affected family member, prenatal testing for a pregnancy at increased risk and preimplantation genetic testing are possible.


GeneReviews staff has selected the following disease-specific and/or umbrella support organizations and/or registries for the benefit of individuals with this disorder and their families. GeneReviews is not responsible for the information provided by other organizations. For information on selection criteria, click here.

  • The Charlie Gard Foundation
    United Kingdom
    Email: hello@thecharliegardfoundation.org
  • United Mitochondrial Disease Foundation
    Phone: 888-317-UMDF (8633)
    Email: info@umdf.org
  • Human Disease Gene Website Series - Registry
  • RDCRN Patient Contact Registry: North American Mitochondrial Disease Consortium

Molecular Genetics

Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.

Table A.

SUCLA2-Related Mitochondrial DNA Depletion Syndrome, Encephalomyopathic Form with Methylmalonic Aciduria: Genes and Databases

Data are compiled from the following standard references: gene from HGNC; chromosome locus from OMIM; protein from UniProt. For a description of databases (Locus Specific, HGMD, ClinVar) to which links are provided, click here.

Table B.

OMIM Entries for SUCLA2-Related Mitochondrial DNA Depletion Syndrome, Encephalomyopathic Form with Methylmalonic Aciduria (View All in OMIM)


Molecular Pathogenesis

SUCLA2 and SUCLG1 encode subunits of succinyl CoA ligase (SUCL). SUCL is a mitochondrial tricarboxylic acid cycle enzyme that catalyzes the reversible conversion of succinyl-CoA and ADP or GDP to succinate and ATP or GTP. SUCL is composed of an alpha subunit, encoded by SUCLG1, and a beta subunit, encoded by either SUCLA2 or SUCLG2. The alpha subunit forms a heterodimer with either of its beta subunits, resulting in an ADP-forming SUCL and a GDP-forming SUCL, respectively. SUCL also forms a complex with the mitochondrial nucleoside diphosphate kinase, and the lack of this complex formation in SUCL deficiency has been suggested to disturb the kinase function, resulting in decreased mitochondrial nucleotide synthesis and therefore decreased mtDNA synthesis leading to mtDNA depletion [Kowluru et al 2002].

Gene structure. SUCLA2 maps to 13q14.2, spans 58 kb, and contains 11 exons. For a detailed summary of gene and protein information, see Table A, Gene.

Pathogenic variants. See Table 4.

Table 4.

Selected SUCLA2 Pathogenic Variants

DNA Nucleotide ChangePredicted Protein ChangeReference Sequences
c.534+1G>A 1-- NM_003850​.2

Variants listed in the table have been provided by the authors. GeneReviews staff have not independently verified the classification of variants.

GeneReviews follows the standard naming conventions of the Human Genome Variation Society (varnomen​.hgvs.org). See Quick Reference for an explanation of nomenclature.


Normal gene product. SUCLA2 encodes the 463 amino acids of the β subunit of the ADP-forming SUCL.

Abnormal gene product. The pathogenic variants lead to dysfunctional SUCL protein. As SUCL forms a complex with the mitochondrial nucleoside diphosphate kinase, the lack of this complex formation in SUCL deficiency can disturb the kinase function, resulting in decreased mitochondrial nucleotide synthesis and therefore decreased mtDNA synthesis leading to mtDNA depletion [Kowluru et al 2002].

Chapter Notes

Author History

Ayman W El-Hattab, MD, FAAP, FACMG (2016-present)
Elsebet Ostergaard, MD, PhD; National University Hospital Rigshospitalet (2009-2016)
Fernando Scaglia, MD, FAAP, FACMG (2016-present)

Revision History

  • 18 May 2017 (aa) Revision: Differential Diagnosis updated
  • 30 June 2016 (ma) Comprehensive update posted live
  • 26 May 2009 (et) Review posted live
  • 16 January 2009 (eo) Original submission


Literature Cited

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  • Carrozzo R, Verrigni D, Rasmussen M, de Coo R, Amartino H, Bianchi M, Buhas D, Mesli S, Naess K, Born AP, Woldseth B, Prontera P, Batbayli M, Ravn K, Joensen F, Cordelli DM, Santorelli FM, Tulinius M, Darin N, Duno M, Jouvencel P, Burlina A, Stangoni G, Bertini E, Redonnet-Vernhet I, Wibrand F, Dionisi-Vici C, Uusimaa J, Vieira P, Osorio AN, McFarland R, Taylor RW, Holme E, Ostergaard E. Succinate-CoA ligase deficiency due to mutations in SUCLA2 and SUCLG1: phenotype and genotype correlations in 71 patients. J Inherit Metab Dis. 2016;39:243–52. [PubMed: 26475597]
  • El-Hattab AW, Scaglia F. Mitochondrial DNA depletion syndromes: review and updates of genetic basis, manifestations, and therapeutic options. Neurotherapeutics. 2013;10:186–98. [PMC free article: PMC3625391] [PubMed: 23385875]
  • Elpeleg O, Miller C, Hershkovitz E, Bitner-Glindzicz M, Bondi-Rubinstein G, Rahman S, Pagnamenta A, Eshhar S, Saada A. Deficiency of the ADP-forming succinyl-CoA synthase activity is associated with encephalomyopathy and mitochondrial DNA depletion. Am J Hum Genet. 2005;76:1081–6. [PMC free article: PMC1196446] [PubMed: 15877282]
  • Jaberi E, Chitsazian F, Ali Shahidi G, Rohani M, Sina F, Safari I, Malakouti Nejad M, Houshmand M, Klotzle B, Elahi E. The novel mutation p.Asp251Asn in the β-subunit of succinate-CoA ligase causes encephalomyopathy and elevated succinylcarnitine. J Hum Genet. 2013;58:526–30. [PubMed: 23759946]
  • Kowluru A, Tannous M, Chen HQ. Localization and characterization of the mitochondrial isoform of the nucleoside diphosphate kinase in the pancreatic beta cell: evidence for its complexation with mitochondrial succinyl-CoA synthetase. Arch Biochem Biophys. 2002;398:160–9. [PubMed: 11831846]
  • Lamperti C, Fang M, Invernizzi F, Liu X, Wang H, Zhang Q, Carrara F, Moroni I, Zeviani M, Zhang J, Ghezzi D. A novel homozygous mutation in SUCLA2 gene identified by exome sequencing. Mol Genet Metab. 2012;107:403–8. [PMC free article: PMC3490101] [PubMed: 23010432]
  • Matilainen S, Isohanni P, Euro L, Lönnqvist T, Pihko H, Kivelä T, Knuutila S, Suomalainen A. Mitochondrial encephalomyopathy and retinoblastoma explained by compound heterozygosity of SUCLA2 point mutation and 13q14 deletion. Eur J Hum Genet. 2015;23:325–30. [PMC free article: PMC4326715] [PubMed: 24986829]
  • Morava E, Steuerwald U, Carrozzo R, Kluijtmans LA, Joensen F, Santer R, Dionisi-Vici C, Wevers RA. Dystonia and deafness due to SUCLA2 defect; Clinical course and biochemical markers in 16 children. Mitochondrion. 2009;9:438–42. [PubMed: 19666145]
  • Navarro-Sastre A, Tort F, Garcia-Villoria J, Pons MR, Nascimento A, Colomer J, Campistol J, Yoldi ME, López-Gallardo E, Montoya J, Unceta M, Martinez MJ, Briones P, Ribes A. Mitochondrial DNA depletion syndrome: new descriptions and the use of citrate synthase as a helpful tool to better characterise the patients. Mol Genet Metab. 2012;107:409–15. [PubMed: 22980518]
  • Nogueira C, Meschini MC, Nesti C, Garcia P, Diogo L, Valongo C, Costa R, Videira A, Vilarinho L, Santorelli FM. A novel SUCLA2 mutation in a Portuguese child associated with “mild” methylmalonic aciduria. J Child Neurol. 2015;30:228–32. [PubMed: 24659738]
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