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Ornithine carbamoyltransferase (OCT) activity was deficient (8% of control) in the liver of a 21-year-old man who died after suddenly becoming comatose. Activities of other enzymes of the urea cycle in the liver were normal. There was no known prior illness or injury; the patient, however, had been taking liquid protein supplements to his diet. Hyperammonemia and orotic aciduria were present, and the concentration of lysine in the plasma was elevated. Survey of earlier reports indicates that neither the specific deficiency of hepatic OCT nor the urine and plasma findings provide a basis for definitive diagnosis of the patient's illness as primary OCT deficiency or as Reye's syndrome. Indeed, the age of the patient at onset of symptoms and the absence of any prodromal infection argue against the OCT deficiency being either primary or a sequel to Reye's syndrome. We suggest that it was secondary to mitochondrial injury caused by an unknown agent. Electron microscopic study of hepatocyte ultrastructure lends support to this view; abnormalities of the patient's mitochondria (bizarre, elongated shapes) do not resemble those seen in Reye's syndrome, nor have abnormalities been found in primary OCT deficiency.

An 18-month-old female infant was found to have citrullinemia on routine plasma screening by the Scriver Method at 5 days of age. At 10 days of age, plasma citrulline concentration was 0.704mumol/ml (normal, 0.010 to 0.030mumol/ml) and has remained 60 to 80 times higher than normal. Urine citrulline concentration was markedly elevated. Hyperammonemia occurred at 1 month of age. The serum ammonia concentration was 473mug/100 ml (normal, 50 to 250 mug/100 ml) and rose to 770mug/100 ml at 4 months of age. Dietary protein was restricted to 1.6 gm/kg/day. Without further change in protein intake, the serum ammonia concentration decreased to 280mug/100 ml and, since then, it has returned to normal. The addition of three synthetic L-amino acids was required for a short time during dietary therapy. At 10 months of age, the infant was given a normal diet. At 18 months of age, her physical and mental development is normal. Activity of argininosuccinic acid synthetase measured in skin fibroblasts was 0.0037mumol of radioactive carbon dioxide per milligram of protein per hour. To demonstrate heterozygosity, fasting plasma citrulline concentrations were measured in five members of the family. Comparison of findings in this patient with those reported in the literature suggests phenotypical variation of the disease, probably due to genetic heterogeneity.