Outlook on ACADSB variants shaping metabolomic patterns and clinical outcomes - experience from a Central European country.

BACKGROUND Short/branched-chain acyl-CoA dehydrogenase deficiency (SBCADD) is an autosomal recessive defect of L-isoleucine catabolism caused by pathogenic variants in the ACADSB gene. While early reports described neurological symptoms, expanded newborn screening cohorts have revealed predominantly asymptomatic individuals, raising questions regarding the clinical significance and optimal management.

METHODS We performed an evaluation of three probands with a biochemical profile consistent with SBCADD identified in a Central European country. Acylcarnitines were measured by liquid chromatography with tandem mass spectrometry, urinary organic acids by gas chromatography with mass spectrometry, and ACADSB was sequenced. Clinical data were collected from regional paediatric follow-up.

RESULTS Three individuals with a biochemical profile consistent with SBCADD were identified in Slovakia. Two were detected through newborn screening, whereas one was diagnosed at 5 years of age. All three showed elevated C5-acylcarnitine; the C5/C8 ratio was increased in two patients, while in the third it remained within the reference range despite persistently elevated C5. Urinary 2-methylbutyrylglycine and 2-ethyl-3-hydroxypropionate were elevated in all cases and showed intra-individual variability; in one sample, 2-methylbutyrylglycine remained increased while 2-ethyl-3-hydroxypropionate had normalised. Two patients carried pathogenic ACADSB variants (one homozygous splice-site variant c.303 + 1G > A, one compound heterozygous for p.Thr148Ile and p.Glu387Lys), whereas genetic testing was not performed in the third case. Over the available follow-up period, no episodes of metabolic decompensation were observed; two patients remained clinically well, and one patient had autism spectrum disorder. Free carnitine concentrations were within the reference range in all probands.

CONCLUSIONS Our findings support SBCADD as a primarily biochemical phenotype with a largely benign course, while illustrating variability of urinary biomarkers and C5/C8 ratios. Accurate differentiation from isovaleric acidemia and careful integration of biochemical, genetic and clinical data remain essential.