(See also Overview of Undernutrition.)
The amino acid carnitine is required for the transport of long-chain fatty acyl coenzyme A (CoA) esters into myocyte mitochondria, where they are oxidized for energy. Carnitine is obtained from foods, particularly animal-based foods, and via endogenous synthesis.
Causes of carnitine deficiency include the following:
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Inadequate intake (eg, due to fad diets, lack of access, or long-term total parenteral nutrition)
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Inability to metabolize carnitine due to enzyme deficiencies (eg, carnitine palmitoyltransferase deficiency, methylmalonicaciduria, propionicacidemia, isovalericacidemia)
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Decreased endogenous synthesis of carnitine due to a severe liver disorder
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Excess loss of carnitine due to diarrhea, diuresis, or hemodialysis
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A hereditary disorder in which carnitine leaks from renal tubules
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Increased requirements for carnitine when ketosis is present or demand for fat oxidation is high (eg, during a critical illness such as sepsis or major burns; after major surgery of the gastrointestinal tract)
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Decreased muscle carnitine levels due to mitochondrial impairment (eg, due to use of zidovudine)
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Use of valproate
The deficiency may be generalized (systemic) or may affect mainly muscle (myopathic).
Symptoms
Diagnosis
In neonates, carnitine palmitoyltransferase deficiency is diagnosed using mass spectrometry to screen blood. Prenatal diagnosis may be possible using amniotic villous cells.
In adults, the definitive diagnosis is based on acylcarnitine levels in serum, urine, and tissues (muscle and liver for systemic deficiency; muscle only for myopathic deficiency).
Treatment
Carnitine deficiency due to inadequate dietary intake, increased requirements, excess losses, decreased synthesis, or (sometimes) enzyme deficiencies can be treated by giving L-carnitine 25 mg/kg orally every 6 hours.
All patients must avoid fasting and strenuous exercise. Consuming uncooked cornstarch at bedtime prevents early morning hypoglycemia.
Some patients require supplementation with medium-chain triglycerides and essential fatty acids (eg, linoleic acid, linolenic acid). Patients with a fatty acid oxidation disorder require a high-carbohydrate, low-fat diet.
