Chapter 10

Glycolysis and
Protein Structure
Gluconeogenesis
and Function
This chapter quizzes the student on the metabolic below. An enzyme that may be defective in this child
aspects of glycolysis and the synthesis of glucose, is which one of the following?
gluconeogenesis. Various aspects of diseases related
to carbohydrate metabolism are also reviewed in
this chapter.

QUESTIONS
Select the single best answer.

1 Anaerobiosis leads to lactate formation in muscle due to

which one of the following?
(A) Inhibiting hexokinase by glucose-6-phosphate
(B) Providing 2,3-bisphosphoglycerate for the phos-
phoglyceromutase reaction
(C) Inhibiting pyruvate kinase by pyruvate
(D) Providing substrate for glyceraldehyde-3-phosphate
dehydrogenase
(E) Inhibiting phosphofructokinase-1 by AMP (A) Fructose-1,6-bisphosphatase
(B) Galactose-1-phosphate uridylyltransferase
2 In muscle, under anaerobic conditions, the net synthesis (C) Galactokinase
of ATP starting from one mole of glucose derived from (D) Glycogen synthase
muscle glycogen is which one of the following? (E) Fructokinase
(A) 1 mole of ATP
(B) 2 moles of ATP 4 A 7-year-old girl, who lives on a farm, started to have
(C) 3 moles of ATP shaking and sweating episodes. Upon physical exami-
nation, she was found to be hypoglycemic under fast-
(D) 4 moles of ATP
ing conditions (fasting blood glucose was 50 mg/dL)
(E) 5 moles of ATP
and positive for ketones in her blood and urine. Her
growth curve is normal. Further analyses showed no
3 A 2-week-old newborn was brought to the pediatri- other metabolic abnormalities. Probing further into her
cian due to frequent vomiting, lethargy, and diarrhea. history, in the absence of her parents, revealed that one
Family history revealed that the child never seemed of her chores was to collect eggs from the chicken coop
to eat well, and had only been breast-fed. Physical every morning, and she had gotten into the habit of
examination revealed an enlarged liver and jaundice. eating one or two raw eggs every morning. This had
The pediatrician was suspicious of an inborn error of been going on for the past 6 weeks or so. A reasonable
metabolism and referred the child to an ophthalmolo- explanation for her laboratory results is which one of
gist for a slitlamp exam, the result of which is shown the following?

78

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 Glycolysis and Gluconeogenesis 79
(A) Reduced levels of electron acceptors in her system, (A) Liver glycogen stores were depleted by the high
leading to reduced glucose production NAD+/NADH ratio
(B) Reduced effectiveness of carboxylation reactions, (B) Liver glycogen stores were depleted by the high
leading to reduced glucose production NADH/NAD+ ratio
(C) Reduced effectiveness of acyl activation, leading to (C) The high NAD+/NADH ratio impaired gluconeo-
reduced glucose production genesis
(D) Reduced effectiveness of protein hydroxylation, (D) The high NADH/NAD+ ratio impaired gluconeo-
leading to reduced enzymatic activity and reduced genesis
glucose production (E) The high NAD+ /NADH ratio impaired glycolysis
(E) Reduced levels of electron donors in her system,
leading to reduced glucose production
7 A 3-month-old girl is brought to the pediatrician due
to fussiness and lethargy. According to the parents, the
5 Mr Smith recently had a bout of five days of severe nau- baby was just fine until the mother needed to return
sea, vomiting, low-grade fever, and diarrhea. This con- to work, and the baby was being switched from breast
dition had afflicted a number of people in Mr Smith’s milk to baby foods, formula, and fruit juices. At that
office. After recovering from this disorder, Mr Smith time, the child cried while feeding, sometimes vomited,
found that he could no longer drink milk before going and had been lethargic. The baby’s appetite seemed to
to bed as he became flatulent, his stomach hurt, and have worsened. The parents thought that if only formula
he would develop diarrhea. If he did not drink milk, was used, the baby was better, but they really could not
these conditions did not occur. He had never experi- remember. Which possible enzyme defect might lead to
enced these problems before the affliction. A possible this case presentation?
explanation for Mr Smith’s problem is which one of the (A) Galactokinase
following? (B) Fructokinase
(A) Mechanical disruption of the intestinal epithelial (C) Aldolase
cells, leading to reduced transcription of the galac-
(D) Hexokinase
tokinase gene
(E) Glucokinase
(B) Mechanical disruption of the intestinal epithelial
cells, leading to reduced transcription of the fruc-
tokinase gene 8 A thin, anxious woman, who is 5′ 6″ tall, weighs 92 lb.
(C) Mechanical disruption of the intestinal epithelial Blood work indicates a glucose level of 70 mg/dL under
cells, leading to loss of lactose transport into the cells fasting conditions. Her liver is using which of the
(D) Mechanical disruption of the intestinal epithelial following as precursors for glucose production under
cells, leading to loss of the glucoamylase complex these conditions?
from their surface (A) Glycerol, lactate, and leucine
(E) Mechanical disruption of the intestinal epithelial (B) Fatty acids, alanine, and glutamine
cells, leading to loss of lactase from their surface (C) Glycerol, lactate, and glutamine
(D) Glycerol, fatty acids, and glutamine
6 Paramedics bring a patient to the emergency depart- (E) Lactate, heme, and lysine
ment because he was found unconscious in an alley
by passers by. The man was unshaven and dishev-
9 A 50-year-old man has been trying to lose weight, but he
elled, and appeared to be about 40 years old. Blood
enjoyed eating so much that he found it difficult to do
alcohol levels were found to be 0.25% and blood
so. He then reads about a product in the popular press,
glucose levels 32 mg/dL. IV glucose was initiated,
which guarantees that he can lose weight, as caloric
and this enabled the man to regain consciousness,
intake due to starch ingestion will be reduced (a starch
although he was still inebriated. While conscious,
blocker). The over-the-counter product that he buys is
a history revealed that the man was a chronic alco-
claimed to inhibit which of the following enzymes?
holic, and as far as he could remember, he had been
only drinking for the past 2 weeks, with nothing (A) Pancreatic trypsinogen
to eat. Analysis of liver enzyme levels in his blood (B) Pancreatic lipase
revealed normal readings. Assuming that his liver is (C) Salivary amylase
still functioning normally, why is this patient hypo- (D) Gastric amylase
glycemic? (E) Intestinal enteropeptidase

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 80 Chapter 10

10 A 28-year-old male develops diabetes, as noted by con- 12 The synthesis of one mole of glucose from two moles of
stant, mildly elevated hyperglycemia. His father had lactate requires six moles of ATP. Which one of the follow-
similar symptoms at the same age as did his paternal ing steps requires ATP in the gluconeogenic pathway?
grandmother. This patient is not obese, does not have (A) Pyruvate kinase
hypertension, does not have dyslipidemia, and does not (B) Triosephosphate isomerase
have antibodies directed against islet cells. This altera- (C) Glucose-6-phosphatase
tion in glucose homeostasis may be due to a mutation in (D) Fructose-1,6-bisphosphatase
which of the following enzymes?
(E) Phosphoglycerate kinase
(A) Pancreatic glucokinase
(B) Pancreatic hexokinase
(C) Liver glucokinase 13 An important product of the oxidation of the body’s
(D) Muscle hexokinase major energy source to provide energy for gluconeogen-
esis regulates which of the following key gluconeogenic
(E) Intestinal glucokinase
enzymes?
11 A 3-month-old girl with developing cataracts is shown (A) PEPCK
to contain a reducing sugar in her urine, but the glu- (B) Fructose-1,6-bisphosphatase
cose oxidase test was negative. She has had no problems (C) Glucose-6-phosphatase
eating, and her growth curve is at the 60th percentile. (D) Pyruvate carboxylase
Fasting blood glucose tests show normal levels of circu- (E) Pyruvate kinase
lating glucose. A likely enzyme deficiency is which of
the following?
14 An individual with a BMI of 34 was advised by the
(A) Fructokinase physician to eat less and exercise more. The patient
(B) Hexokinase took this advice to an extreme, and has not eaten for
(C) Galactokinase 48 h. Which of the following best describes the patient’s
(D) Galactose-1-phosphate uridylyltransferase activity and phosphorylation state of the following key
(E) Aldolase liver enzymes?

Phosphofructokinase-1 Glucokinase Pyruvate Kinase

Activity Phosphorylated? Activity Phosphorylated? Activity Phosphorylated?

(A) Low Yes Low No Low Yes

(B) Low No Low No Low No
(C) Low No Low Yes Low Yes
(D) Low Yes Low No Low No
(E) Low No Low No Low Yes

15 Which of the following changes in enzyme activity will

occur within 1 h of a type 1 diabetic taking an injection
of insulin?

Muscle Glucose
Liver PFK-2 Liver PFK-1 Uptake
(A) Active kinase Active kinase Increased
(B) Inactive kinase Active kinase Increased
(C) Active phosphatase Active kinase Increased
(D) Inactive phosphatase Active kinase Decreased
(E) Active kinase Inactive kinase Decreased

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 Glycolysis and Gluconeogenesis 81

16 Streptococcus mutans, found in dental plaque, produces 19 Your 20-year-old male patient received a medical
acids from the metabolism of carbohydrates. Topical discharge from the US Army. He has had multiple
fluoride treatment in the dental office can slow the pro- episodes of lightheadedness, sweating, fatigue, tremor,
duction of acids, resulting in the accumulation of which and intense hunger. He had one seizure. During two
metabolite? of these episodes, his blood glucose was 40 mg/dL.
(A) Glucose-6-phosphate Which of the following tests could help you diagnose
(B) Fructose-1,6-bisphosphate his problem?
(C) Glyceraldehyde-3-phosphate (A) Fasting blood glucose
(D) 2-phosphoglycerate (B) HbA1c
(E) Phosphoenolpyruvate (C) Noncontrast CT scan of the abdomen
(D) Blood glucose and insulin levels measured while he
was symptomatic
17 After eating a meal containing carbohydrates, the mono- (E) Determining the presence of islet cell antibodies
saccharides must be absorbed from the intestinal lumen.
This transport is dependent on which of the following
enzymes? 20 Under conditions of hypoglycemia, the liver is not uti-
(A) Na+/H+ antiporter lizing glucose as an energy source due to which of the
(B) Glucose-6-phosphate dehydrogenase following?
(C) Hexokinase (A) A low Km for glucokinase
(D) Chloride transporter (B) A high Km for glucokinase
(E) Na+, K+ ATPase (C) An inhibited, phosphorylated PFK-1
(D) An activated, phosphorylated PFK-1
18 Skeletal muscle PFK-2 is not regulated by phospho- (E) A reduction of glucose transporters in the membrane
rylation, but heart muscle PFK-2 is. In the heart,
phosphorylation of PFK-2 leads to what effect?
(A) Enhanced production of fructose-2,6-bisphosphate
(B) Reduced production of fructose-2,6-bisphosphate
(C) Degradation of fructose-1,6-bisphosphate
(D) Increased turnover of PFK-2
(E) Increased transcription of PFK-2

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 82 Chapter 10

ANSWERS regenerating NAD+ for use in glycolysis, specifically as

a substrate for the glyceraldehyde-3-phosphate dehy-
1 The answer is D: Providing substrate for glyceraldehyde- drogenase reaction. While hexokinase is inhibited by
3-phosphate dehydrogenase. Under anaerobic condi- its product glucose-6-phosphate, this allosteric effect
tions, the NADH generated by the glyceraldehyde-3- does not explain lactate formation under anaerobic con-
phosphate dehydrogenase step accumulates. Normally, ditions. Similarly, while phosphoglyceromutase does
the NADH would transfer its electrons to mitochondrial require 2,3-bisphosphoglycerate, anaerobiosis does not
NAD+, and the electrons would be donated to the elec- increase 2,3-bisphosphoglycerate levels, nor does it alle-
tron transfer chain. However, in the absence of oxygen viate the lack of NAD+ under these conditions. Pyruvate
kinase is not inhibited by pyruvate (ATP and alanine
Glucose are the allosteric inhibitors of this enzyme). AMP is an
ATP activator of phosphofructokinase-1; however, this acti-
NADH vation does not relate to lactate formation under anaero-
Pyruvate bic conditions. The figure summarizes these key points
outlined above.
NADH
Lactate Acetyl CoA 2 The answer is C: Three moles of ATP. When glycogen
Anaerobic
produces glucose via the action of glycogen phosphory-
glycolysis TCA lase, glucose-1-phosphate is produced. As this is con-
cycle
verted to two molecules of pyruvate, four moles of ATP
are generated and one is utilized at the PFK-1 step for
NADH is generated by the glyceraldehyde 3-phosphate
dehydrogenase reaction; in the absence of oxygen, NAD+
the net production of three moles of ATP. Two moles of
is regenerated by the lactate dehydrogenase reaction. In NADH are also produced, but those are utilized by lac-
the presence of oxygen, NADH donates its electrons to the tate dehydrogenase to reduce pyruvate to lactate (anaer-
electron transfer chain (regenerating NAD+), which eventually obic conditions) such that NAD+ can be regenerated for
donates the electrons to oxygen, forming water.
the glyceraldehyde-3-phosphate dehydrogenase step.
A small amount of free glucose will be released from
the electron transfer chain is not functioning. Thus, glycogen by the debranching enzyme (about 5% of the
as NADH accumulates in the cytoplasm, the levels of total); for that glucose, the net yield is two moles of ATP
NAD+ decrease to the point that there would be insuf- (since hexokinase has to phosphorylate the free glucose
ficient NAD+ available to allow the glyceraldehyde-3- to glucose-6-phosphate), but since the majority of glu-
phosphate dehydrogenase reaction to proceed, thereby cose released is in the form of glucose-1-phosphate,
inhibiting glycolysis. To prevent glycolytic inhibition, three moles of ATP is the better answer. These reactions
lactate dehydrogenase will convert pyruvate to lactate, are outlined below.

Glycogen

2-phosphoglycerate Phosphoenolpyruvate

2ADP

Glucose 1-phosphate 2ATP

3-phosphoglycerate Pyruvate
2NADH + 2H+
2ATP

Glucose 6-phosphate 2ADP 2NAD+

1,3 bisphosphoglycerate Lactate
2NADH + 2H+
Pi
Fructose 6-phosphate The flow of carbons is from
2NAD+
glycogen to lactate under
ATP Glyceraldehyde 3-phosphate anaerobic conditions.

ADP
Fructose 1,6-bisphosphate

Dihydroxyacetone phosphate

Answer 2

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 Glycolysis and Gluconeogenesis 83

3 The answer is B: Galactose-1-phosphate uridylyltrans- need of oxaloacetate for gluconeogenesis, acetyl-CoA

ferase. The child has classic galactosemia, a defect derived from fatty acid oxidation increases, leading to
in galactose-1-phosphate uridylyltransferase. Due to ketone body formation. Avidin does not affect NAD+ or
the accumulation of galactose-1-phosphate, galac- FAD levels, nor does it interfere with coenzyme A or
tokinase is inhibited, and free galactose accumulates vitamin C.
within the blood and tissues. The accumulation of
galactose in the lens of the eye provides substrate 5 The answer is E: Mechanical disruption of the intesti-
for aldose reductase, converting galactose to its alco- nal epithelial cells, leading to loss of lactase from their
hol form (galactitol). The accumulation of galactitol surface. Mechanical disruption of the intestinal epi-
leads to an osmotic imbalance across the lens, lead- thelial cells (as brought about by acute viral gastro-
ing to cataract formation. Additionally, the increased enteritis) leads to a loss of cell surface enzymes, but
galactose-1-phosphate, at very high levels in the lactase is the most severely affected, as it is present at
liver, blocks phosphoglucomutase activity, result- the lowest levels on these cells. While glucoamylase is
ing in ineffective glucose production from glycogen also lost, its activity is in vast excess of what is required
(phosphorylase degradation of glycogen will produce and its partial loss does not affect its ability to hydro-
glucose-1-phosphate, but this cannot be converted to lyze glucose–glucose linkages (it does not hydrolyze
glucose-6-phosphate if phosphoglucomutase activ- lactose). A lack of lactase means that the lactose in the
ity is inhibited). A defect in galactokinase will lead diet passes undigested through the small intestine to
to nonclassical galactosemia, with cataract formation, the large intestine where the bacterial flora metabolize
but none of the feeding problems associated with clas- the lactose, producing gases and acids that disrupt the
sical galactosemia (associated with the accumulation osmotic balance between the lumen of the bowel and
of galactose-1-phosphate) are observed in nonclassi- the cells lining it. This leads to water secretion by the
cal galactosemia. None of the other enzymes listed, cells into the lumen of the bowel, resulting in diar-
if deficient, will give rise to the symptoms produced, rhea. Lactose is not directly transported by intestinal
particularly cataract formation. A defect in glycogen epithelial cells (its components, glucose and galactose,
synthase would lead to reduced glycogen levels and are, after hydrolysis of β-1,4 linkage between the two
fasting hypoglycemia. A defect in fructokinase leads sugars), and a mechanical disruption of intestinal cells
to fructosuria (fructose in the urine), but no overt does not alter transcription of galactokinase and fruc-
symptoms of disease. The figure below indicates the tokinase.
pathway for galactose metabolism and the defects in
classical and nonclassical galactosemia. 6 The answer is D: The high NADH/NAD+ ratio impaired
gluconeogenesis. Ethanol oxidation to acetic acid (via
acetaldehyde) generates large amounts of NADH. As
Galactose Nonclassical galactosemia liver glycogen stores have been depleted within 36 h of
ATP Classical galactosemia
Galactokinase the fast, gluconeogenesis is required to maintain blood
ADP glucose levels. The major precursors for gluconeogen-
Galactose 1-phosphate esis are glycerol, lactate, and amino acids (which give
UDP-
Galactose 1-phosphate
uridylyltransferase
rise to pyruvate or TCA cycle precursors, which gen-
glucose Glucose 1-phosphate erate oxaloacetate). Because of the high NADH/NAD+
Epimerase
UDP- ratio (due to the ethanol metabolism), pyruvate des-
galactose tined for gluconeogenesis is shunted to lactate in order
Glucose 6-phosphate Glycolysis
(Liver)
(other tissues) to regenerate NAD+ to allow alcohol metabolism to con-
tinue. Similarly, oxaloacetate is shunted to malate, also
Glucose
to regenerate NAD+ for ethanol metabolism. Glycerol,
which is converted to glycerol-3-phosphate, cannot go
4 The answer is B: Reduced effectiveness of carboxylation to dihydroxyacetone phosphate due to the high NADH
reactions, leading to reduced glucose production. Raw levels in the liver. Thus, the high NADH/NAD+ ratio
eggs contain a potent binding partner to biotin, avidin, diverts gluconeogenic precursors from entering gluco-
which, while bound to biotin, blocks biotin’s participa- neogenesis, and the liver has trouble maintaining ade-
tion in carboxylation reactions. This leads to reduced quate blood glucose levels. Liver glycogen stores have
activity of pyruvate carboxylase, a necessary step in been depleted within the first 36 h of the fast, but glyco-
many gluconeogenic pathways, thereby leading to a gen regulation is not affected by the NADH/NAD+ ratio.
reduced ability of the liver to properly maintain blood Under conditions in which the liver is exporting glucose
glucose levels. As oxaloacetate levels drop due to the (glucagon administration, for example), liver glycolysis

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 84 Chapter 10

Pyruvate 7 The answer is C: Aldolase. The disorder is hereditary

fructose intolerance, with a reduced ability to convert
NADH
+ H+ fructose-1-phosphate to dihydroxyacetone phosphate
NAD+
and glyceraldehyde. The specific defect is in aldolase B,
with its activity reduced by as much as 85%. This prob-
CH3 CH2OH Lactate lem is only evident when sucrose is introduced into the
Ethanol diet, and fructose enters the liver. The accumulation
NAD+
Oxaloacetate of fructose-1-phosphate, due to the reduced aldolase
ADH Glucose NADH activity, leads to a constellation of physiological prob-
NADH + H+ + H+ lems resulting in nausea, vomiting, and hypoglyce-
NAD+ mia. Elimination of fructose from the diet will reverse
O the symptoms. Galactokinase is needed for galactose
CH3 C Malate
H metabolism; since the patient digests milk normally
Acetaldehyde
Dihydroxyacetone galactokinase activity is not altered. Similarly, glucose
NAD+ phosphate metabolism is not adversely affected (milk contains
ALDH NADH lactose, which is split into glucose and galactose), indi-
NADH + H+ + H+ cating that hexokinase and glucokinase activities are
NAD+ normal. The defect in aldolase B will hinder glycoly-
O
CH3 C sis, but the liver also contains aldolase C activity (this
O– Glycerol 3-phosphate
isozyme will not split fructose-1-phosphate), which
Acetate enables glucose metabolism to be very close to normal.
A deficiency in fructokinase will lead to an accumula-
tion of fructose (not fructose-1-phosphate), which is
Glycerol
released into the urine (fructosuria), but does not lead
to the physiological symptoms exhibited by the patient.
is inhibited by covalent modification of key regulatory The fructose pathway (indicating the reaction catalyzed
enzymes, not the NADH/NAD+ ratio. These pathways by aldolase B), and its relationship to glycolysis, is
are indicated in the figure above. shown below.

Glucose Glycogen
ATP
Fructose Hexokinase
ATP ADP
Fructokinase
ADP Glucose 6- Glucose 1-
phosphate phosphate
Fructose 1-phosphate
Aldolase B Fructose 6-
phosphate
Dihydroxyacetone-phosphate
Glyceraldehyde Fructose 1,6-phosphate
ATP Aldolase B (liver)
Triose kinase Aldolase A (muscle)
ADP

Glyceraldehyde 3-phosphate Dihydroxy acetone- Glyceraldehyde 3-

phosphate phosphate

Lactate Pyruvate

Fatty acids
TCA cycle

Answer 7

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 Glycolysis and Gluconeogenesis 85

8 The answer is C: Glycerol, lactate, and glutamine. The is a mutation in pancreatic glucokinase. MODY3 is a
woman has a BMI in the unhealthy range (15.7), indi- mutation in the transcription factor HNF1-α while
cating inadequate nutrient uptake. Since her nutrient MODY4 contains a mutation in insulin promoter factor
uptake is poor, most of the glucose present in her blood 1. MODY5 is a mutation in another transcription factor,
is derived from gluconeogenesis, as her glycogen stores HNF1-β. MODY6 is a mutation in neurogenic differen-
are most likely depleted. The substrates for gluconeo- tiation factor 1. MODY is not insulin resistance. There-
genesis are lactate (derived from red blood cell meta- fore, all the other aspects of insulin resistance syndrome
bolism), glycerol (from triglyceride degradation), and are not present (obesity, hypertension, and hypertrig-
amino acids derived from protein muscle degradation. lyceridemia). Since MODY is autosomal dominant, it
Glutamine is a glucogenic amino acid, and is also used can be traced through the family tree. It was thought
to transport nitrogen groups from the muscle to the liver at one time that the patient had to be young to present
for safe excretion via the urea cycle. Leucine is a strictly with this disorder, but patients up to age 50 have been
ketogenic amino acid (giving rise only to acetyl-CoA), reported. It is not type 1 diabetes mellitus as no islet
and leucine carbons cannot be used to make glucose cell antibodies are present. Glucokinase is acting as a
via gluconeogenesis. Fatty acids are also strictly keto- glucose sensor for the β-cell. A mutated, less sensitive
genic, and cannot be used for glucose production (fatty sensor leads to mildly elevated blood glucose levels.
acids give rise to acetyl-CoA, which cannot be used to
produce net glucose). Lysine is also a strictly ketogenic 11 The answer is C: Galactokinase. The child has non-
amino acid, and cannot be used for glucose production. classical galactosemia, a defect in galactokinase. With
Heme degradation gives rise to bilirubin, which cannot this disorder, galactose cannot be accumulated within
be further degraded, and none of the carbons of heme cells, and so it accumulates in the blood, spilling over
can be used for glucose production. to the urine. Because of its high level, the galactose can
enter the eye and be reduced to galactitol by aldose
reductase, trapping the galactitol within the eye. As
9 The answer is C: Salivary amylase. Starch blockers con- galactitol accumulates, an osmotic imbalance is created,
tain a natural inhibitor of salivary amylase, which will leading to cataract formation. However, since galactose-
block starch digestion in the mouth. The other amylase 1-phosphate is not accumulating (as occurs in classical
that digests starch, pancreatic amylase, would only be galactosemia, a defect in galactose-1-phosphate uridylyl
inhibited by the starch blocker if the inhibitor would transferase), the other effects seen with classical galac-
survive the conditions of the acidic stomach with- tosemia (hypoglycemia and neurological deficit) do not
out becoming denatured. There is no gastric amylase. occur. The sugar that is accumulating in the urine is
Intestinal enteropeptidase activates trypsinogen, which galactose, which contains an aldehyde, which gener-
is required for protein digestion, not starch digestion. ates a positive response in a reducing test. A defect in
Pancreatic lipase is required for dietary triglyceride fructokinase leads to fructosuria, a benign condition
digestion, and is not active toward starch. (fructose is not a substrate for aldose reductase, as it
is a ketose and not an aldose). A defect in hexokinase
10 The answer is A: Pancreatic glucokinase. The boy would lead to elevated glucose levels, and can lead to
has developed MODY (maturity onset diabetes of the sorbitol production in the lens of the eye, but the urine
young), and one variant of MODY is a mutated glucoki- reducing sugar test was negative for glucose. A defect in
nase (an inheritable disorder) such that the Km for glu- aldolase would lead to the intracellular accumulation
cose has increased, and insulin release only occurs when of metabolites, but not a great increase in circulating
hyperglycemia is present. Both an increase in ATP and galactose. Refer to the figure in the answer to question 3
NADPH are required for the pancreatic β-cell to release of this chapter for the pathway of galactose metabolism
insulin. When pancreatic glucokinase has an increased and the enzyme defects in both classical and nonclassi-
Km for glucose, ATP levels can only increase at greater cal galactosemia.
than normal levels of glucose. Thus, moderate hypergly-
cemia is not sufficient to induce insulin release. As insulin 12 The answer is E: Phosphoglycerate kinase. In glu-
release occurs from the pancreas, liver, muscle, or intes- coneogenesis, phosphoglycerate kinase catalyzes the
tinal hexokinase will not affect the process. The pancreas phosphorylation of 3-phosphoglycerate to 1,3-bispho-
does not express hexokinase, only glucokinase. MODY sphoglycerate, a step which requires ATP. The other two
is a monogenetic autosomal dominant disease of insulin steps requiring a high-energy phosphate bond in the
secretion. There are at least six amino acid substitutions conversion of pyruvate to glucose are pyruvate carboxy-
known in a number of different proteins. MODY1 is a lase and phosphoenolpyruvate carboxykinase. Fructose-
mutation in the transcription factor HNF4-α:∼ MODY2 1,6-bisphosphatase and glucose-6-phosphatase are

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 86 Chapter 10

enzymes that remove phosphates from substrates, isomerase catalyzes the conversion of dihydroxyacetone
releasing the phosphates as inorganic phosphate. They phosphate and glyceraldehyde-3-phosphate, without
do not require, nor generate, ATP. Pyruvate kinase is the involvement of a high-energy phosphate bond.
not utilized for gluconeogenesis, and triose phosphate These are shown in the pathway below.

Glucose

Pi
glucose 6-phosphatase

Glucose 6-phosphate

Fructose 6-phosphate

Pi
fructose 1,6-bisphosphatase

Fructose 1,6-bisphosphate

Dihydroxyacetone-P Glyceraldehyde-3-P

Glycerol Glycerol-3-P REQUIRES ATP (to convert 3-phosphoglycerate

to 1,3 bisphosphoglycerate)

Phosphoenolpyruvate
REQUIRES GTP
phosphoenolpyruvate carboxykinase
TCA Oxaloacetate
Amino cycle Amino
acids acids
Alanine
pyruvate
carboxylase Pyruvate

REQUIRES ATP Lactate

13 The answer is D: Pyruvate carboxylase. The body’s induced phosphorylation of PFK-2, which activates
major energy source for gluconeogenesis is fatty acids, PFK-2 phosphatase activity, which converts fructose-2,
which are oxidized to acetyl-CoA, at which point acetyl- 6-bisphosphate to fructose-6-phosphate. Pyruvate kinase
CoA enters the TCA cycle to produce ATP. Acetyl-CoA activity, in the liver, is also reduced by phosphorylation
activates pyruvate carboxylase (and inhibits pyruvate by protein kinase A (which is activated by glucagon).
dehydrogenase), a key gluconeogenic enzyme. Acetyl- As blood glucose levels have dropped during the fast,
CoA does not regulate any of the other enzymes listed and the liver is exporting glucose, the concentration of
as potential answers (PEPCK is transcriptionally regu- glucose in the hepatocyte is not sufficient for glucoki-
lated by CREB; Fructose-1,6-bisphosphatase is inhibited nase (which has a high Km) to phosphorylate glucose.
by fructose-2,6-bisphosphate; glucose-6-phosphatase is Glucokinase is not regulated by phosphorylation.
regulated by a regulatory protein; and pyruvate kinase
has both allosteric and covalent controls in the liver, but 15 The answer is A. Upon insulin release, the cAMP phos-
none involve acetyl-CoA). phodiesterase is activated, reducing cAMP levels in the
liver, thereby leading to inactivation of protein kinase A.
14 The answer is E. Under the conditions of a 48-h fast, the In addition, protein phosphatase 1 has become active and
liver is exporting glucose, and glycolysis will be inhibited. dephosphorylates the enzymes that were phosphorylated
PFK-1 activity is reduced due to a reduction of fructose- by protein kinase A. Therefore, PFK-2 is not phospho-
2,6-bisphosphate levels, brought about by glucagon- rylated, which leads to an active kinase activity and an

Chap10.indd 86 8/27/2009 1:30:58 PM

 Glycolysis and Gluconeogenesis 87
inactive phosphatase activity (choices A, D, or E). The lumen into the enterocyte. The energy for active trans-
active kinase of PFK-2 produces more fructose-2,6-bis- port of the carbohydrate is derived from the sodium
phosphate, leading to the activation of PFK-1 (answers gradient that is established by the Na+, K+ ATPase,
A through D; combined with PFK-2 activity, now only which pumps sodium out of the cell (three atoms of
choice A or D can be correct). Insulin stimulates pre- sodium) in exchange for potassium (two atoms of
formed GLUT4 transporters in the muscle to fuse with the potassium). This creates both a sodium gradient (out-
plasma membrane, thereby enhancing glucose transport side concentration higher) and a charge gradient (out-
into the muscle (choices A through C; combined with the side positive as compared to inside the cell) across the
other two columns, only choice A can be correct). plasma membrane. Due to these gradients, the entry
of sodium into the cell is energetically favorable, and
16 The answer is D: 2-phosphoglycerate. Fluoride inhibits the monosaccharide piggybacks with the sodium for
the glycolytic enzyme enolase, which catalyzes the dehy- transport into the cell. The Na /H+ exchanger is not
dration of 2-phosphoglycerate to phosphoenolpyruvate. operative in intestinal epithelial cells, and none of the
Thus, 2-phosphoglycerate accumulates under these other enzymes (glucose-6-phosphate dehydrogenase,
conditions. hexokinase, and chloride transporter) will create the
necessary sodium gradient for monosaccharide trans-
17 The answer is E: Na+, K+ ATPase. Most monosaccha- port. Carbohydrate transport into the enterocytes is
rides are transported with sodium from the intestinal outlined in the figure below.

Lumen
Na+
Fructose Glucose Galactose
Mucosal side

Brush
border

Intestinal
ATP epithelium

3 Na+
Fructose Glucose Na+
2 K+ 3 Na+
Galactose
ADP
+ Pi 2 K+

Serosal side
To capillaries

, Na+–glucose cotransporters , Facilitated glucose transporters , Na+,K+-ATPase

18 The answer is A: Enhanced production of fructose-2, 19 The answer is D: Blood glucose and insulin levels
6-bisphosphate. When phosphorylated, heart PFK-2 measured while he was symptomatic. This patient
is activated to produce more fructose-2,6-bisphosphate probably has an insulinoma that releases insulin inap-
to stimulate heart PFK-1 and to increase the glycolytic propriately at any blood glucose level, which would
rate of the heart. Phosphorylation of heart PFK-2 can be lead to hypoglycemia. The released insulin would stim-
accomplished through the AMP-activated protein kinase ulate glucose uptake into the peripheral tissues (muscle
(when the heart is having trouble generating energy) and fat), and if the patient had not eaten, blood glucose
or in response to insulin (indicating that high levels of levels would rapidly fall. The insulin is also inhibiting
glucose are available for use). Phosphorylation of heart the liver from producing glucose, either from glyco-
PFK-2 does not affect its transcription or turnover rate, gen degradation or gluconeogenesis, which only com-
and also does not affect the degradation of fructose-1, pounds the problem. The hypoglycemia and resultant
6-bisphosphate. epinephrine release account for all of his symptoms.

Chap10.indd 87 8/27/2009 1:30:59 PM

 88 Chapter 10

To diagnose an insulinoma, a low blood glucose level 20 The answer is B: A high Km for glucokinase. The liver
and an inappropriately high insulin level during symp- expresses glucokinase, which has a high Km for glucose,
toms must be documented. A fasting blood glucose and particularly as compared to the Km for hexokinase. This
HbA1c could be perfectly normal and do not help in means that glucokinase will only phosphorylate glucose
making the diagnosis, as insulinomas do not necessar- when the intrahepatic glucose concentrations are high,
ily constantly secrete insulin; they do so episodically. and the intrahepatic levels of glucose only reach these
The presence of islet cell antibodies helps diagnose type levels after a meal. Under normal, fasting conditions,
1 diabetes mellitus, but not an insulinoma. A noncon- the concentration of blood glucose is lower than the Km
trast CT scan might be used to locate the position of the for glucokinase, and very little phosphorylation of glu-
insulinoma, but it is a very poor test even for location cose will occur. PFK-1 is not a phosphorylated enzyme,
and would only be attempted once the diagnosis was and glucagon does not stimulate an increase in glucose
confirmed. transporters in the liver.

Chap10.indd 88 8/27/2009 1:30:59 PM

 Chapter 11

TCA Cycle
and Oxidative
Phosphorylation
This chapter contains questions on the TCA cycle (A) Ethanol is converted to acetone, and the carbons
and oxidative phosphorylation, including questions are lost during exhalation
integrated with other aspects of metabolism. Meta- (B) Ethanol is lost directly in the urine
bolic diseases affecting aspects of the TCA cycle (C) Ethanol cannot enter the liver, where gluconeogen-
and oxidative phosphorylation are also covered esis predominantly occurs
in this chapter. (D) Ethanol’s carbons are lost as carbon dioxide before
a gluconeogenic precursor can be generated
QUESTIONS (E) Ethanol is converted to lysine, which is strictly a
ketogenic amino acid
Select the single best answer.
4 A family that had previously had a newborn boy die of
1 A chronic alcoholic, while out on a binge, became very
a metabolic disease has just given birth to another boy,
confused and forgetful. The police found the man and
small for gestational age, and with low Apgar scores. The
brought him to the emergency department. Upon exam-
child displayed spasms a few hours after birth. Blood
ination, he displayed nystagmus and ataxia. Which
analysis indicated extremely high levels of lactic acid.
enzyme is displaying reduced activity in his brain under
Analysis of cerebrospinal fluid showed elevated lactate
these conditions?
and pyruvate. Hyperalaninemia was also observed. The
(A) Glyceraldehyde-3-phosphate dehydrogenase child died within 5 days of birth. The biochemical defect
(B) Isocitrate dehydrogenase in this child is most likely which of the following?
(C) α-ketoglutarate dehydrogenase (A) The E1 subunit of pyruvate dehydrogenase
(D) Succinate dehydrogenase (B) The E2 subunit of pyruvate dehydrogenase
(E) Malate dehydrogenase (C) The E3 subunit of pyruvate dehydrogenase
(D) Citrate synthase
2 The energy yield from the complete oxidation of acetyl- (E) Malate dehydrogenase
CoA to carbon dioxide is which of the following in terms
of high-energy bonds formed? 5 A 3-month-old girl developed lactic acidemia.
(A) 6 Blood analysis also indicated elevated levels of pyru-
(B) 8 vate, α-ketoglutarate, and branched-chain amino
(C) 10 acids. A urinalysis showed elevated levels of lactate,
pyruvate, α-hydroxyisovalerate, α-ketoglutarate, and
(D) 12
α-hydroxybutyrate. A likely mutation in which of the
(E) 14
following proteins would lead to this clinical finding?
(A) The E1 subunit of pyruvate dehydrogenase
3 Ethanol ingestion is incapable of supplying carbons (B) The E2 subunit of pyruvate dehydrogenase
for gluconeogenesis. This is due to which of the fol- (C) The E3 subunit of pyruvate dehydrogenase
lowing? (D) Citrate synthase
(E) Malate dehydrogenase

89

Chap11.indd 89 8/27/2009 11:34:27 AM

 90 Chapter 11

6 A human geneticist is studying two different families. In energy yield for the complete oxidation of citrate to six
one family, all of the children of a mildly affected mother carbon dioxides and water is which of the following?
display myoclonic epilepsy, developmental display, and (A) 15.0 moles of ATP per mole of citrate
abnormal muscle biopsy (ragged red fibers). In the other (B) 17.5 moles of ATP per mole of citrate
family, the three children of an affected woman endure (C) 20.0 moles of ATP per mole of citrate
strokelike episodes and a mitochondrial myopathy. (D) 22.5 moles of ATP per mole of citrate
The common link between these two diseases is which (E) 25.0 moles of ATP per mole of citrate
of the following?
(A) Mutations in pyruvate dehydrogenase complex
11 You have been following a patient for several years, who
(B) Mutations in cytoplasmic tRNA
has recently become clinically depressed, and is eating
(C) Mutations in mitochondrial tRNA very little and drinking alcohol very heavily. He presents
(D) Mutations in malate dehydrogenase to you one day with noticeable swelling of the lower
(E) Mutations in pyruvate carboxylase legs, increased heart rate, lung congestion, and com-
plaints of shortness of breath with virtually any activity.
7 A toddler has been diagnosed with a mild case of Leigh These symptoms have come about due to which of the
syndrome. One possible treatment is which of the fol- following?
lowing? (A) Lack of energy to the nervous system due to niacin
(A) Increased carbohydrate diet deficiency
(B) Additional B6 in the diet (B) Heart has trouble generating energy due to niacin
(C) Decreased lipoamide in the diet deficiency
(D) Additional thiamine in the diet (C) Lack of energy to the nervous system due to B1 defi-
(E) Decreased fat diet ciency
(D) Lack of energy to the heart due to B1 deficiency
8 A patient was diagnosed with a mitochondrial DNA (E) Lack of TCA cycle activity in the kidneys, leading to
mutation that led to reduced complex I activity. This excessive water retention
patient would have difficulties in which of the following
electron transfers? 12 An 8-month-old girl was taken to the emergency
(A) Succinate to complex III department due to the onset of sudden seizures. The
(B) Cytochrome c to complex IV child had brittle hair, with some bald spots, and skin
(C) Coenzyme Q to complex III rashes. An ophthalmologist noted optic atrophy. Urinal-
(D) Malate to coenzyme Q ysis showed slightly elevated ketones and the presence
of other organic acids (such as propionate and lactate).
(E) Coenzyme Q to oxygen
Treatment of this child with which of the following can
successfully alleviate the problems?
9 A pair of farm workers in Mexico was spraying pesti-
(A) Thiamine
cide on crops when they both developed the following
(B) Niacin
severe symptoms: heavy, labored breathing, significantly
elevated temperature, and loss of consciousness. The (C) Riboflavin
pesticide contained an agent that interfered with oxi- (D) Carnitine
dative phosphorylation, which most closely resembled (E) Biotin
which of the following known inhibitors?
(A) Oligomycin 13 The refilling of TCA cycle intermediates is frequently
(B) Atractyloside dependant upon which of the following cofactors?
(C) Cyanide (A) Niacin
(D) Rotenone (B) Riboflavin
(E) Dinitrophenol (C) Carnitine
(D) Pyridoxal phosphate
10 A crazed friend of yours has gone on an orange juice, (E) Lipoate
fish, and vitamin pill diet. He tells you that the citric acid,
since it is a component of the TCA cycle, is always recy- 14 The concentration of TCA cycle intermediates can be
cled and does not count toward his caloric total each day. reduced under certain conditions. Consider a patient
You disagree, and inform him that citrate can, in addition who initiates taking barbiturates. During the initial
to having its carbons stored as glycogen or fat for later phase of his taking this drug, which TCA cycle interme-
use, produce energy for his daily metabolic needs. The diate is reduced in concentration?

Chap11.indd 90 8/27/2009 11:34:27 AM

 TCA Cycle and Oxidative Phosphorylation 91
(A) Citrate 17 An inactivating mutation in which of the following
(B) α-ketoglutarate enzymes would lead to lactic acid accumulation in the
(C) Succinyl-CoA liver?
(D) Fumarate (A) Glucokinase
(E) Oxaloacetate (B) Phosphofructokinase-1
(C) Cytoplasmic malate dehydrogenase
Questions 15 and 16 are based on the following graph of oxy-
gen consumption by carefully washed mitochondria as a func- (D) Pyruvate kinase
tion of time. ATP, ADP, inorganic phosphate, and oxygen are (E) Glycerol-3-phosphate dehydrogenase
present, but no oxidizable substrates. Once a compound is
added to the mixture, it is not removed, nor is the length of the 18 A researcher was studying oxidative phosphorylation
experiment sufficient to use up all of the compounds added to in a suspension of carefully washed and isolated mito-
the mitochondrion. chondria. ATP, ADP, inorganic phosphate, lactate, lactate
dehydrogenase, and oxygen were introduced to the sus-
pension, and he was able to demonstrate ATP production
within the mitochondria. The researcher then added oli-
gomycin to the mixture, which stopped oxygen uptake.
1 = Pyruvate This occurred due to which of the following?
Oxygen consumption

2 = Succinate
(A) Inhibition of complex I
3 = Oligomycin 4
(B) Inhibition of complex II
4 = Cyanide
(C) Inhibition of complex III
(D) Inhibition of complex IV
3 B (E) Inhibition of the proton translocating ATPase

A 2 19 A newborn displays lethargy and crying episodes. Blood

analysis indicates lactic acidosis and hyperalaninemia.
1 In order to distinguish between a pyruvate dehydro-
genase complex deficiency and a pyruvate carboxylase
Time deficiency, one can measure which of the following in
the blood?
(A) Fasting blood glucose
15 What compound was added at the point indicated as A? (B) Alanine aminotransferase activity
(A) Antimycin A (C) Free fatty acids levels when fasting
(B) Atractyloside (D) Insulin levels when fasting
(C) Rotenone (E) Glucagon levels when fasting
(D) Dinitrophenol
(E) Lactate 20 Your obese patient has type 2 diabetes mellitus and you
have started him on metformin. One of the possible
complications of metformin therapy is lactic acidosis.
16 What compound was added at the point indicated as B? Why is this a concern with metformin therapy?
(A) Antimycin A (A) Metformin reduces insulin resistance
(B) Atractyloside (B) Metformin blocks hepatic gluconeogenesis
(C) Rotenone (C) Metformin blocks the TCA cycle
(D) Dinitrophenol (D) Metformin inhibits glycolysis
(E) Lactate (E) Metformin inhibits dietary protein absorption

Chap11.indd 91 8/27/2009 11:34:28 AM

 92 Chapter 11

ANSWERS molecules of NADH are produced, along with one mol-

ecule of FADH2 and one substrate-level phosphoryla-
1 The answer is C: a-ketoglutarate dehydrogenase. The tion resulting in the generation of GTP. As each NADH
alcoholic has become deficient in vitamin B1, thiamine, can give rise to 2.5 ATP, and each FADH2 to 1.5 ATP via
which is converted to thiamine pyrophosphate for use oxidative phosphorylation, the net yield of high-energy
as a coenzyme. One of the symptoms of B1 deficiency bonds from one acetyl-CoA being oxidized by the cycle
is neurological, due to insufficient energy generation is 10 (7.5 from NADH, 1.5 from FADH2, and 1 from
within the nervous system. B1 is required for a small GTP). This is shown in the figure below.
number of enzymes, including transketolase, pyruvate
dehydrogenase, and α-ketoglutarate dehydrogenase. By 3 The answer is D: Ethanol’s carbons are lost as car-
reducing the activity of the latter two enzymes, glucose bon dioxide before a gluconeogenic precursor can be
oxidation to generate energy is impaired, and the ner- generated. Ethanol is converted to acetaldehyde, which
vous system suffers because of it. is further oxidized to acetic acid and is then activated to
acetyl-CoA. The acetyl-CoA enters the TCA cycle to gen-
2 The answer is C: 10. When acetyl-CoA enters the erate energy, and two carbons are lost for each turn of
TCA cycle, and is converted to two molecules of the cycle as CO2. Thus, ethanol cannot provide carbons
carbon dioxide, and oxaloacetate is regenerated, three for the net synthesis of glucose. Ethanol is not converted

O
CH3C SCoA
Acetyl CoA
–
COO
CoASH
C O COO–
Citrate synthase
CH2 CH2
H2O
Malate – –
COO HO C COO
dehydrogenase
Oxaloacetate CH2
– Aconitase
COO
– COO
NADH Citrate COO–
HO CH + H+
NAD+
CH2
CH2
–
– H C COO
COO
Malate HO C H

Electron- COO–
H2O ATP transport Isocitrate
Fumarase chain
NAD+
COO– Oxidative
CO2
phosphorylation NADH + H+
HC H2O O2
Isocitrate
CH COO– dehydrogenase
COO– CH2
Fumarate
FAD(2H) NADH CH2
+ H+ C O
FAD
COO– NAD+
COO–
Succinate –
dehydrogenase
CH2 COO α–Ketoglutarate
CoASH CH2
CH2 CO2
–
COO CH2 CoASH α-Ketoglutarate
Succinate GDP C O dehydrogenase
+ Pi
˜

Succinate SCoA
thiokinase
GTP
Succinyl CoA

Answer 2: The Krebs tricarboxylic acid cycle.

Chap11.indd 92 8/27/2009 11:34:28 AM

 TCA Cycle and Oxidative Phosphorylation 93
to acetone, nor is it directly lost in the urine. Ethanol from that of an E2 or E3 deficiency. In addition, an
is primarily oxidized in the liver, and its carbons can- E3 deficiency would affect more than pyruvate metab-
not be used for the biosynthesis of lysine, which is an olism, as this subunit is shared with other enzymes
essential amino acid for humans. Ethanol oxidation is that catalyze oxidative decarboxylation reactions,
outlined in the figure below. and other metabolites would also be accumulating.
Defects in citrate synthase and malate dehydrogenase
CH3 CH2OH would not lead to severe lactic acidosis and would not
Ethanol
be male-specific disorders. As an example, the three
subunits of α-ketoglutarate dehydrogenase are shown
NAD+ below.
ADH
NADH + H+
5 The answer is C: The E3 subunit of pyruvate dehy-
O drogenase. The child is defective in a variety of
CH3 C oxidative decarboxylation reactions (pyruvate dehy-
H
Acetaldehyde
drogenase, leading to a buildup of lactate and pyruvate;
α-ketoglutarate dehydrogenase, leading to the buildup
NAD+ of α-ketoglutarate; and branched-chain α-ketoacid
ALDH
NADH + H+
dehydrogenase, leading to a buildup of many of the
other metabolites). Enzymes, which catalyze oxidative
O decarboxylation reactions, contain three catalytic sub-
CH3 C
O–
units, E1, E2, and E3 (see the figure in the answer to
the previous question). E3 subunit, which contains the
Acetate
dihydrolipoyl dehydrogenase activity, is common among
Ethanol metabolism. these enzymes. Thus, a mutation in E3 would render
all of these enzymes inoperable, leading to a buildup of
the α-ketoacid precursors. Defects in citrate synthase or
4 The answer is A: The E1 subunit of pyruvate dehydro- malate dehydrogenase would not lead to the buildup of
genase. Lactic acidosis can result from a defect in an these α-ketoacids.
enzyme that metabolizes pyruvate (primarily pyruvate
dehydrogenase and pyruvate carboxylase). The pyru- 6 The answer is C: Mutations in mitochondrial tRNA.
vate dehydrogenase complex consists of three major Both families are suffering from mitochondrial dis-
catalytic subunits, designated E1, E2, and E3. The eases. Family 1 has MERRF (myoclonic epilepsy with
E1 subunit is the one that binds thiamine pyrophos- ragged red fibers) while family 2 has MELAS (mito-
phate and catalyzes the decarboxylation of pyruvate. chondrial myopathy, encephalopathy, lactic acidosis,
The gene for the E1 subunit is on the X chromosome, and stroke). Both disorders are due to mutations in
so defects in this subunit are inherited as X-linked a mitochondrially encoded tRNA. MERRF is a muta-
diseases, which primarily affects males. Since this is tion in tRNAlys, whereas MELAS has a mutation in a
the second male child to have these symptoms, it is tRNAleu gene. In both cases, the tRNA mutations inter-
likely that the mother is a carrier for this disease. The fere with protein synthesis within the mitochondria,
pattern of inheritance distinguishes this diagnosis leading to a reduction of functional proteins necessary

OH
R C TPP FAD (2H) NAD+
S Dihydrolipoyl DH
H S Lip E3 5
Answer 4: Mechanism of α-keto acid dehy- a-Keto FAD
CO2 trans Ac 4 NADH
drogenase complexes. R represents the por- acid DH
+ H+
tion of the α-keto acid that begins with the β SH
1 E1 2 E2 trans Ac
carbon. Three different subunits are required R Lip SH
for the reaction, E1 (α-keto acid decarboxy- O
C O trans Ac 3
lase), E2 (transacylase), and E3 (dihydrolipoyl a-Keto
R C SCoA
dehydrogenase). TPP refers to the cofactor thi- COO– acid DH
Lip O
amine pyrophosphate. Lip refers to the cofac- CoASH
a-Keto acid TPP HS S C R
tor lipoic acid.

Chap11.indd 93 8/27/2009 11:34:29 AM

 94 Chapter 11

for various aspects of oxidative phosphorylation. 9 The answer is E: Dinitrophenol. The key is the elevation
These disorders are not due to mutations in nuclear in temperature. Dinitrophenol is an uncoupler of oxi-
encoded genes (which eliminates all of the other dation and phosphorylation in that uncouplers destroy
answers). the proton gradient across the membrane (thereby
inhibiting the synthesis of ATP) without blocking the
transfer of electrons through the electron transfer chain
7 The answer is D: Additional thiamine in the diet. Leigh to oxygen. The energy that should have been generated
syndrome can result from a deficiency of pyruvate in the form of a proton gradient is lost as heat, which
dehydrogenase (PDH) activity, leading to lactic acido- elevates the body temperature of the affected workers.
sis. In some cases, the enzyme has a reduced affinity Electron flow is also enhanced in the presence of an
for thiamine pyrophosphate, a required cofactor for uncoupler, so additional oxygen is required to allow
the enzyme. Adding thiamine to the diet may over- the chain to continue (hence the heavy breathing). The
come this deficiency by raising the concentration other agents added would have stopped electron trans-
of thiamine pyrophosphate such that it will bind to fer totally, which would not allow for an increase in
the altered enzyme. Increasing the carbohydrate in temperature, and would actually decrease the rate of
the diet will make the disease worse, as more pyru- breathing (since oxygen is no longer required for the
vate would be generated due to the increase in the nonfunctioning electron transfer chain). Atractyloside
glycolytic rate. Vitamin B6 does not play a role in gly- inhibits the ATP/ADP exchanger, and once there is no
colysis or the PDH reaction. Lipoamide is a required ADP in the mitochondrial matrix, electron flow will
cofactor for the PDH reaction, so reducing lipoam- stop due to the inability to synthesize ATP (normal
ide would have an adverse effect on the activity of coupling). Oligomycin works in a similar mechanism
PDH. Decreasing the fat content of the diet may be in that it blocks the ATP synthase, preventing ATP syn-
harmful, particularly if the calories are replaced as thesis, and, due to coupling, electron transfer through
carbohydrate. the chain. Rotenone blocks complex I transfer to coen-
zyme Q, which significantly reduces electron flow, and
will not lead to an increase in temperature.
8 The answer is D: Malate to coenzyme Q. Complex I
accepts electrons from NADH, and will transfer them to 10 The answer is D: 22.5 moles of ATP per mole of citrate.
coenzyme Q. Malate dehydrogenase will convert malate The following steps (see the figure on page 95) are
to oxaloacetate, generating NADH in the process. The required for the complete oxidation of citrate to car-
NADH will then donate electrons to complex I to ini- bon dioxide and water. First, citrate goes to isocitrate,
tiate electron transfer. Succinate donates electrons at which goes to α-ketoglutarate (this last step generates
complex II (via succinate dehydrogenase, a component carbon dioxide and NADH, which can give rise to 2.5
of complex II), which donates to coenzyme Q, thereby ATP). The α-ketoglutarate is further oxidized to suc-
bypassing complex I. Cytochrome c transfers electrons cinyl-CoA, plus carbon dioxide and NADH (this is the
from complex III to complex IV. Once electrons are car- second carbon released as CO2, and another 2.5 ATP).
ried by coenzyme Q, complex I is no longer required for Succinyl-CoA is converted to succinate, generating a
electron transfer to oxygen. These transfers are outlined GTP (at this point, five high-energy bonds have been
in the figure below. created, plus two carbons lost as carbon dioxide).

Intermembrane Glycerol
space 3-phosphate 4H+ 2H+
4H+
dehydrogenase Cyt c
CoQH2 CoQH2 Fe–S Cyt c1 CuA
FAD
Fe-S Cyt a
I Cyt b
CoQ II CoQ Cyt a3
FMN Fe-S
Fe-S CuB
FAD (FAD) IV
NADH NAD+ III
Succinate
1/2 O2 + 2H+ H2O
NADH Succinate ETF: Q Cytochrome b–c1 Cytochrome c
dehydrogenase dehydrogenase oxidoreductase complex oxidase
Matrix

Answer 8: Electron flow through the electron-transport chain.

Chap11.indd 94 8/27/2009 11:34:32 AM

 TCA Cycle and Oxidative Phosphorylation 95
Succinate goes to fumarate, with the generation of 11 The answer is D: Lack of energy to the heart due to B1
FADH2 (another 1.5 ATP), fumarate is converted to deficiency. The patient has thiamine deficiency, and
malate, and malate leaves the mitochondria (via the because of this, his heart is having trouble generating
malate/aspartate shuttle) for further reactions. Once sufficient energy to effectively pump his blood (due to
in the cytoplasm, the malate is oxidized to oxaloace- a reduction in the rate of both pyruvate oxidation and
tate, generating NADH (another 2.5 ATP if the malate/ TCA oxidative steps). The resultant congestive heart
aspartate shuttle is used). At this point, citrate has failure leads to edema in the lower extremities, pulmo-
been converted to cytoplasmic oxaloacetate, with the nary edema, and inability to participate in even mild
generation of ten high-energy bonds and the loss of exercise. The thiamine deficiency has resulted from the
two carbons as carbon dioxide. The oxaloacetate is patient’s poor diet and the effect of ethanol blocking
then converted to phosphoenolpyruvate and carbon thiamine absorption from the diet. The nervous system
dioxide at the expense of a high-energy bond (GTP, also suffers from thiamine deficiency, in which case,
the phosphoenolpyruvate carboxykinase reaction). neurological signs of the deficiency would be evident.
The high-energy bond is recovered in the next step, These are not yet observed in this patient. The symp-
however, as PEP is converted to pyruvate, generating toms observed are not due to niacin deficiency (which
an ATP. Thus, at this point in our conversion, citrate are dementia, dermatitis, and diarrhea). The problem
has gone to pyruvate, plus three CO2, with a net yield is also not due to insufficient energy for the kidney to
of ten ATP (or high-energy bonds). The pyruvate re- appropriately filter the blood.
enters the mitochondria and is oxidized to acetyl-CoA
and carbon dioxide, also generating NADH (another
2.5 ATP). When this acetyl-CoA goes around the TCA 12 The answer is E: Biotin. The child has biotinidase defi-
cycle, two carbon dioxide molecules are produced, ciency, which results in a functional biotin deficiency.
along with another ten high-energy bonds. The net Biotinidase is required to remove covalently linked
total is therefore six carbon dioxide molecules and biotin from proteins in our diet and from proteins that
22.5 high energy bonds for the complete oxidation of have turned over within the body. An inability to do this
citrate. leads to a biotin deficiency (as most ingested biotin is

NAD+ NADH NAD+ NADH

Citrate Isocitrate α-ketoglutarate Succinyl-CoA
GDP
CO2 CO2
GTP

Malate Malate Fumarate Succinate

(cyto) (mito)
HOH FADH2 FAD
NAD+

NADH
GTP GDP ADP ATP NAD+ NADH
Oxaloacetate PEP Pyruvate Acetyl-CoA

CO2 CO2

Overall, then, there are TCA Cycle, which

6 carbon dioxide generated generates:
7 NADH (which yield 17.5 ATP) 2 CO2
2 FADH2 (which yields 3 ATP) 3 NADH
1 GTP 1 FADH2
1 ATP 1 GTP
For a total of 22.5 moles of
ATP per mole of citrate

Answer 10: The pathway required for the complete oxidation of citrate to carbon dioxide and water.

Chap11.indd 95 8/27/2009 11:34:34 AM

 96 Chapter 11

linked to proteins). The hair and scalp problems have 14 The answer is C: Succinyl-CoA. Barbiturates are metabo-
been attributed to an inability to synthesize fatty acids lized via cytochrome P450 enzymes, which are induced
(as acetyl-CoA carboxylase is missing biotin). Since by their substrates. The induction of synthesis requires
pyruvate carboxylase is also inoperative (due to the that heme be synthesized, and the first step in heme
lack of biotin), gluconeogenesis is impaired, and ketone synthesis requires succinyl-CoA and glycine and occurs
bodies will be synthesized by the liver to compensate for within the mitochondrial matrix (see the figure below).
reduced glucose production. Priopionyl-CoA carboxy- Thus, succinyl-CoA levels can drop in the matrix during
lase is also impaired, leading to the elevated levels of pro- heme synthesis, and anaplerotic reactions are required
pionic acid. Since gluconeogenesis is impaired, excess to keep the cycle going.
pyruvate will be converted to lactate since it cannot be
converted to oxaloacetate. The optic atrophy may be due COO–
to an inability to synthesize fatty acids within the neurons
CH2
or a lack of energy due to reduced gluconeogenesis.
CH2

13 The answer is D: Pyridoxal phosphate. Pyridoxal C O

phosphate is required for the transamination of aspar- SCoA
tate to oxaloacetate and glutamic acid to α-ketoglutarate.
Succinyl CoA
Both the α-keto acids are TCA cycle components, and
when their levels decrease, they can be replenished +
+
through such a reaction. Niacin, riboflavin, and lipoate H2C NH3
are required for oxidative decarboxylation reactions, COO–
but that reaction type does not lead to a refilling of TCA
Glycine
cycle intermediates. Carnitine is required to transport
acyl groups into the mitochondria and is not used to δ-ALA
PLP
transport TCA cycle intermediates from the cytoplasm to synthase
the mitochondria. Biotin would be a correct answer (for CO2
CoAS–
the pyruvate carboxylase reaction, to regenerate oxalo-
acetate from pyruvate), but it was not offered as a choice. COO–
A typical transamination reaction is shown below. CH2
CH2
A
Amino acid1 a-Keto acid1 C O
+
H2C NH3
PLP
a-Keto acid2 Amino acid2
δ-Aminolevulinic acid
(δ-ALA)

B The first step in heme biosynthesis.

– –
COO COO
+
H3N C H C O 15 The answer is C: Rotenone. At point 1, an oxidizable
CH2 CH2 substrate was added to the mixture as indicated in the
– figure (pyruvate), which is oxidized to form NADH. The
COO COO–
NADH can add electrons to complex I to initiate elec-
Aspartate Oxaloacetate
tron flow across the chain. Since at point 2 the addi-
PLP tion of succinate allows electron flow to reoccur, after
COO– COO– being inhibited, it suggests that the inhibitor added at
+ point A blocks electron flow from complex I to complex
C O H3N C H
III (recall, succinate will add electrons at complex II,
CH2 CH2 bypassing complex I). The only inhibitor in the list that
CH2 CH2 does this is rotenone. Antimycin A blocks electron flow
COO –
COO– from complex III to complex IV. Atractyloside blocks
a-Ketoglutarate Glutamate ATP/ADP exchange across the inner mitochondrial mem-
brane and will stop electron flow due to an inhibition of
Panel A indicates the general reaction for a transamination reaction phosphorylation. The addition of succinate would not be
whereas Panel B shows the transamination between aspartic acid and able to overcome an inhibition of ATP synthesis due to
α-ketoglutarate. lack of substrate (ADP). Dinitrophenol is an uncoupler,

Chap11.indd 96 8/27/2009 11:34:35 AM

 TCA Cycle and Oxidative Phosphorylation 97
but would not allow electron flow from complex 1 in the 18 The answer is E: Inhibition of the proton translocating
presence of rotenone. Lactate is another oxidizable sub- ATPase. Oligomycin blocks the F0 component of the
strate, which would not overcome the block of electron proton-translocating ATPase, thereby blocking proton
transfer from complex I as lactate oxidation will gener- flow through the enzyme and ATP synthesis. Oligomy-
ate NADH, which adds electrons to complex I. cin does not affect any other complex of oxidative phos-
phorylation.
16 The answer is D: Dinitrophenol. The increase in oxygen
uptake stimulated by succinate (which is allowing electron
19 The answer is A: Fasting blood glucose. A pyruvate
flow from complex II to oxygen) is being blocked by oli-
carboxylase deficiency will impair gluconeogenesis from
gomycin, which inhibits ATP synthesis. The block in ATP
lactate and pyruvate, thereby leading to fasting hypogly-
synthesis leads to the cessation of oxygen consumption
cemia more easily than a pyruvate dehydrogenase defi-
due to the coupling of oxidation and phosphorylation. The
ciency (which will primarily affect the ability to generate
only drug that can allow electron flow, in the absence of
energy from carbohydrates). Alanine amino transferase
ATP synthesis, is an uncoupler, which uncouples the link
activity in the blood is a measure of liver damage, which
between oxygen consumption and ATP production. Dini-
would not distinguish between the two possibilities.
trophenol is the only uncoupler on the list of answers. Note
Free fatty acid levels would be the same under both
also that the rate of oxygen consumption has increased as
conditions, during fasting conditions, as would insulin
compared to that when either NADH or succinate was
and glucagon levels.
donating electrons. This is due to the lack of a proton gra-
dient in the presence of an uncoupler, so there is no “back
pressure” to oxygen consumption, and the electron flow is 20 The answer is B: Metformin blocks hepatic gluconeo-
faster than in the absence of the uncoupler. genesis. Metformin leads to a reduction of hepatic
gluconeogenesis. This is accomplished through the
17 The answer is C: Cytoplasmic malate dehydrogenase. The activation of the AMP-activated protein kinase, which
cytoplasmic malate dehydrogenase is required in liver as phosphorylates and sequesters within the cytoplasm
part of the malate/aspartate shuttle in transferring reducing TORC2, which is a coactivator of CREB activity (a
equivalents across the inner mitochondrial membrane. In transcription factor needed for expression of two glu-
the absence of such an activity, NADH levels will build up coneogenic enzymes, PEP carboxykinase and glucose-
in the cytoplasm (since the electrons cannot be transferred 6-phosphatase). Thus, when TORC2 is absent from the
to the mitochondrial matrix) and will lead to the reduc- nucleus, gluconeogenesis is impaired as the synthesis of
tion of pyruvate to lactate to regenerate NAD+ for other two key enzymes is greatly reduced. One of the major
cytoplasmic reactions. A defect in glucokinase will block gluconeogenic precursors is lactate, generated from
glycolysis, with no pyruvate or lactate formation from the red blood cells and exercising muscle. In the Cori
glucose. The same is true for an inactivating mutation cycle, two lactates are converted to one glucose, which
in PFK-1. If pyruvate kinase were defective, PEP would is then exported. If gluconeogenesis is blocked, lactate
accumulate, which cannot be converted to lactate without is not utilized and its levels can increase, and poten-
forming pyruvate first. A defect in glycerol-3-phosphate tially lead to lactic acidosis. However, in the absence of
dehydrogenase will prevent the glycerol-3-phosphate congestive heart failure or renal insufficiency, this does
shuttle from transferring electrons to the mitochondrial not occur. The heart, with its massive amount of mus-
matrix, but the liver uses primarily the malate/aspartate cle and mitochondria, can utilize the lactate for energy
shuttle for this activity. See the figure below for an over- unless the heart is dysfunctional or has lost muscle
view of the malate/aspartate shuttle system. mass. Good, functional kidneys can also overcome

Cytosol Mitochondrion
Glucose
2 NAD+ Malate Malate NAD+

2 NADH Oxaloacetate Oxaloacetate NADH

Electron-
2 Pyruvate α-KG α-KG transport
TA TA chain
Glutamate Glutamate

Aspartate Aspartate

Inner mitochondrial membrane

Answer 17

Chap11.indd 97 8/27/2009 11:34:38 AM

 98 Chapter 11

the lactate imbalance caused by metformin treatment. does not inhibit the TCA cycle, glycolysis, or dietary
Metformin does decrease the insulin resistance, but this protein absorption. These interactions are outlined in
does not increase lactate in the aerobic state. Metformin the figure below.

LKB1
Metformin + TORC2 TORC2
AMPK AMPK PO43–
+
CREB
TORC2
PO43–
Sequester in CREB
cytoplasm TORC2

PGC1α
expression
TORC2 sequestration in the cytoplasm
after phosphorylation by the AMP-
Glucose Enhanced Increased activated protein kinase, which is acti-
export gluconeogenesis gluconeogenic
vated by metformin treatment. This
gene expression
leads to reduced synthesis of key glu-
Nuclear coneogenic enzymes, thereby reducing
membrane gluconeogenesis in the liver.

Chap11.indd 98 8/27/2009 11:34:40 AM

 Chapter 12

Glycogen
Metabolism
This chapter quizzes the student on various symptoms. At the pediatrician’s office, an inborn error
aspects of the synthesis and degradation of the of metabolism was considered, which could explain the
major carbohydrate storage molecule in the body. hypoglycemia. Which explanation is most likely?
Regulation of these processes is also key as is the (A) Fructose inhibition of the debranching enzyme
understanding of the multitude of diseases that (B) Galactose-1-phosphate inhibition of glycogen phos-
alter glycogen metabolism. phorylase
(C) Fructose-1-phosphate inhibition of glycogen phos-
phorylase
QUESTIONS (D) Fructose-6-phosphate inhibition of glycogen phos-
Select the single best answer. phorylase
(E) Galactose inhibition of aldolase
1 A 3-month-old infant was brought to the pediatrician due
to muscle weakness (myopathy) and poor muscle tone 4 A 6-month-old infant was brought to the pediatri-
(hypotonia). Physical exam revealed an enlarged liver cian due to fussiness and a tender abdomen. The child
and heart, and heart failure. The infant had always fed seemed to do well until the time between feeding was
poorly, had failure to thrive, and had breathing problems. increased to more than 3 h. The baby always seemed
He also had trouble holding up his head. Blood work hungry and irritable if not fed frequently. Upon exami-
indicated early liver failure. A liver biopsy indicated that nation, hepatomegaly and enlarged kidneys were noted,
glycogen was present and of normal structure. A poten- and blood work showed fasting hypoglycemia. Subse-
tial defect in this child is which of the following? quent laboratory analysis demonstrated that in response
(A) Liver glycogen phosphorylase to a glucagon challenge, only about 10% of the normal
(B) Liver glycogen synthase amount of glucose was released into circulation, which
(C) Liver α-glucosidase significantly contributed to the fasting hypoglycemia.
(D) Liver debranching enzyme Which enzyme defect in the patient is the most likely?
(E) Liver branching enzyme (A) Glycogen synthase
(B) Branching enzyme
2 A 7-year-old boy is brought to the pediatrician due to (C) Debranching enzyme
severe exercise intolerance. In gym class, the boy has (D) Glucose-6-phosphatase
trouble with anaerobic activities. Laboratory tests showed (E) Fructose-1,6-bisphosphatase
a lack of lactate production under such conditions. The
boy was eventually found to have a mutation in which 5 A 4-month-old infant is seen by the pediatrician for fail-
one of the following enzymes? ure to thrive. Examination shows distinct hepatosple-
(A) Liver glycogen phosphorylase nomegaly. Lab results show elevated transaminases and
(B) Liver PFK-1 bilirubin, suggestive of liver failure. The boy dies shortly
(C) Muscle PFK-1 thereafter, and upon autopsy, precipitated carbohydrate
(D) Muscle glucose-6-phosphatase was found throughout the liver. The boy most likely had
(E) Liver glucose-6-phosphatase a mutation in which of the following enzymes?
(A) Glycogen phosphorylase
3 A 3-month-old infant, when switched to a formula diet (B) Debranching enzyme
plus fruit juices, begins to vomit and displays severe (C) Glycogen synthase
hypoglycemia after eating. Removal of the fruit juices (D) β-glucosidase
from the diet seemed to reduce the severity of the (E) Branching enzyme

99

Chap12.indd 99 8/27/2009 1:07:22 PM

 100 Chapter 12

6 An inactivating mutation in which of the following pro- 11 Patients with von Gierke disease display hepatomegaly.
teins can lead to fasting hypoglycemia? Glycogen content in the liver is increased, relative to
(A) Liver PFK-1 normal, due to which of the following effects of glucose-
(B) Liver glucokinase 6-phosphate in these patients?
(C) Adenylate cyclase (A) Inhibition of phosphorylase a
(D) Galactokinase (B) Stimulation of phosphorylase b
(E) Fructokinase (C) Inhibition of glycogen synthase I
(D) Stimulation of glycogen synthase D
7 If the turnover number of all enzymes involved in gly- (E) Inhibition of glycogen phosphorylase kinase
cogen metabolic regulation and activity is 100 reac-
tions per second, how many glucose molecules could 12 The hyperuricemia observed in patients with von Gierke
be removed from glycogen in 1 s upon activation of one disease comes about due to which of the following?
molecule of protein kinase A (PKA)? (A) Glucose-6-phosphate inhibition of kidney tubule
(A) 100 absorption of urate
(B) 1,000 (B) Lactate inhibition of kidney tubule absorption of
(C) 10,000 urate
(D) 100,000 (C) Glucose-6-phosphate inhibition of glucose-6-
(E) 1,000,000 phosphate dehydrogenase activity
(D) Glucose-6-phosphate stimulation of glycogen syn-
8 An individual is taking a serene walk in the park when thase D
he spots an escaped alligator from the zoo. The individ- (E) Glucose-6-phosphate activation of amidophospho-
ual runs away as fast as he can. Glycogen degradation ribosyl transferase activity
is occurring to supply glycolysis with a substrate even
before epinephrine has reached the muscle. This is due
13 Consider the case of an athlete who has just completed
to which of the following?
a work out. At this point, the athlete consumes a sports
(A) Sudden decrease in blood glucose levels
drink, which contains a large amount of glucose, which
(B) Increase in sarcoplasmic calcium levels enters the circulation. Glycogen degradation is inhib-
(C) Insulin binding to muscle cell receptors ited in the liver under these conditions, prior to insulin
(D) Decline in ATP levels release, due to allosteric inhibition of which of the fol-
(E) Lactate production lowing enzymes?
(A) Glycogen synthase I
9 As the individual in the previous question continues to (B) Phosphorylase kinase a
run from the alligator, the muscle begins to import glu-
(C) Phosphorylase a
cose from the circulation. This occurs due to which of
(D) Protein phosphatase 1
the following?
(E) Adenylate kinase
(A) Insulin binding to muscle cells
(B) Epinephrine binding to muscle cells
(C) Glucagon binding to muscle cells 14 A muscle cell line has been developed with a nonfunc-
(D) Increase in intracellular AMP levels tional adenylate cyclase gene. Glycogen degradation can
be induced in this cell line via which of the following
(E) Increase in intracellular calcium levels
mechanisms?
10 An 18-year-old man visits the doctor due to exercise (A) Addition of glucagon
intolerance. His muscles become stiff or weak during (B) Addition of epinephrine
exercise, and he sometimes cramps up. At times, his (C) Increase in intracellular magnesium
urine appears reddish-brown after exercise. An ischemic (D) Increase in intracellular AMP
forearm exercise test indicates very low lactate produc- (E) Increase in intracellular ADP
tion. A potential enzyme defect in this man is which of
the following?
15 A researcher created a liver cell line that displayed
(A) Muscle glycogen phosphorylase very low levels of glycogen. The glycogen that was
(B) Liver glycogen phosphorylase synthesized was of normal structure, but the overall lev-
(C) Liver PFK-1 els of glycogen were about 5% of normal. Which of the
(D) Muscle glucose-6-phosphatase following is a potential alteration in the cell line that
(E) Muscle GLUT4 transporters would lead to these results?

Chap12.indd 100 8/27/2009 1:07:22 PM

 Glycogen Metabolism 101
(A) An altered glycogen synthase with a reduced Km for 16 Ten hours into a fast, in a normal individual, which of
UDPglucose the following best represents the activity and phospho-
(B) An altered phosphorylase kinase with an increased rylation state of a number of key enzymes within the
Km for glycogen liver?
(C) An altered UTPglucose-1-phosphate uridyl trans-
ferase with a decreased Km for glucose-1-phosphate
(D) An altered glycogenin with an increased Km for
UDPglucose
(E) An altered phosphorylase kinase with an increased
Km for glycogen synthase

PFK-1 Glycogen Synthase Phosphorylase Kinase Pyruvate Dehydrogenase

Active? Phosphorylated? Active? Phosphorylated? Active? Phosphorylated? Active? Phosphorylated?

(A) No Yes No Yes Yes Yes No Yes
(B) No No No No Yes Yes No Yes
(C) No No No Yes Yes Yes No No
(D) No No No Yes Yes No No Yes
(E) No No No Yes Yes Yes No Yes

17 A woman with nonclassical galactosemia is consider- used to produce glycogen in the liver. Which one of
ing becoming pregnant and is concerned that she will the following liver enzymes is required for this conver-
be unable to synthesize lactose in order to breast-feed sion to occur?
her child. Her physician, who recalls her biochemistry, (A) α-ketoglutarate dehydrogenase
tells her this should not be a problem, and that she (B) Pyruvate carboxylase
will be able to synthesize lactose at the appropriate (C) Pyruvate kinase
time. This is true due to the presence of which of the (D) PFK-1
following? (E) Glucose-6-phosphatase
(A) Galactose-1-phosphate uridyl transferase
(B) Phosphoglucomutase
(C) Fructokinase 20 Your patient is a marathon runner and has visited your
office to ask you about carbohydrate loading to increase
(D) Aldolase
his performance during a race. For a full week prior to
(E) Phosphohexose isomerase
a race, he eats three meals a day of pancakes, potatoes,
brown rice, and pasta and does not exercise at all. He
18 The energy required to store one molecule of glucose- has not noticed any success with this regimen. Which
6-phosphate as a portion of glycogen is which of the of the following answers best explains why he is getting
following? no benefit from his “carb loading”?
(A) One high-energy bond (A) Carbohydrate loading is a myth
(B) Two high-energy bonds (B) He is not depleting glycogen stores prior to
(C) Three high-energy bonds loading
(D) Four high-energy bonds (C) He is not on the carbohydrate loading diet long
(E) No high-energy bonds enough prior to the race
(D) He is eating the incorrect foods for carbohydrate
19 An individual has been eating a large number of loading
oranges during the winter months to protect against (E) He is too highly trained as an athlete for anything to
getting a cold. The excess carbons of citrate can be increase his performance

Chap12.indd 101 8/27/2009 1:07:22 PM

 102 Chapter 12

ANSWERS enzyme is a lysosomal enzyme, and nondegraded

glycogen accumulates in the lysosome, interfering with
1 The answer is C: Liver a-glucosidase. The infant has lysosomal function (hence, a lysosomal storage disease).
Pompe disease, a loss of liver α-glucosidase activity. The malfunctioning of the lysosomes is what leads to the
This is glycogen storage disease II. The finding of nor- muscle and liver problems. A defect in glycogen phospho-
mal glycogen structure eliminates liver debranching rylase (liver) would lead to fasting hypoglycemia, and an
and branching activities as being deficient. The missing enlarged liver, but not the muscle problems exhibited by

The catabolism of glycogen and an indication of some of the enzymes that are deficient in various glycogen storage diseases. Glycogen phospho-
rylase hydrolyzes the α-1,4 linkages in glycogen, releasing glucose-1-phosphate. The debranching enzyme transfers a small number of glucose
residues from branch points and adds them to a longer chain of sugars (reaction 1). The debranching enzyme also removes the α-1,6-linked
sugar at the original branch point (reaction 2). Once glucose-1-phosphate is converted to glucose-6-phosphate, glucose is released by the action
of glucose-6-phosphatase. A small proportion of glycogen is totally degraded within lysosomes by acid α-glucosidase.

Chap12.indd 102 8/27/2009 1:07:22 PM

 Glycogen Metabolism 103
the child. A defect in glycogen synthase would also lead which is exported (10% of the expected) is derived from
to fasting hypoglycemia, but would not lead to severe the activity of debranching enzyme, which hydrolyzes
muscle and liver disease. Additionally, in an individual an α-1,6-glucose linkage, which produces free glu-
with a defect in glycogen synthase, glycogen would not cose. The hepatomegaly arises due to excess glycogen
be found in the liver biopsy since it could not be formed. in the liver (glucose-6-phosphate will activate glycogen
The figure on page 102 summarizes steps involved in synthase D), as does the increase in kidney size. A pic-
glycogen degradation, and the glycogen storage disease ture of a 25-month-old untreated child with this disor-
that results if an enzyme is defective. der is shown below. A lack of glycogen synthase would
not lead to hepatomegaly, while a lack of branching
enzyme leads to a different glycogen storage disease,
2 The answer is C: Muscle PFK-1. The child has a form of with very different symptoms. A lack of debranching
glycogen storage disease known as type VII, Tarui dis- activity would not lead to hepatomegaly and would
ease, which is a lack of muscle phosphofructokinase 1 allow more glucose release than is observed through the
(PFK-1) activity. The lack of muscle PFK-1 means that normal action of glycogen phosphorylase. A defect in
glycolysis is impaired, so anaerobic activities are signifi- fructose-1,6-bisphosphatase would impair gluconeo-
cantly curtailed in such individuals. Slow, aerobic activi- genesis, but should not affect the ability of glycogen to
ties, which can be powered by fatty acid oxidation, are be degraded to raise blood glucose levels.
normal in such children. Strenuous activity will lead
to muscle damage and weakness due to this block in
glycolysis. Glucose-6-phosphatase is only found in the
liver (and to a small extent, the kidney), and a lack of
such activity would lead to fasting hypoglycemia, but
would not affect muscle glycolytic activity. A defect in
liver PFK-1 activity would not affect muscle glycolysis.
A defect in liver glycogen phosphorylase would also
lead to fasting hypoglycemia, but would not alter the
rate of muscle glycolysis, or lactate formation from that
pathway.

3 The answer is C: Fructose-1-phosphate inhibition of A 25-month-old child with von Gierke disease. Note the hepatomegaly
glycogen phosphorylase. The child has hereditary and eruptive xanthomas on the arms and legs. The child is in the third
fructose intolerance, a defect in aldolase B activity in percentile for height and weight, indicating a failure to thrive.
the liver. This leads to an accumulation of fructose-1-
phosphate in the liver (and, as fructokinase has a high
Vmax, a large amount of fructose-1-phosphate accumu- 5 The answer is E: Branching enzyme. The child has a
lates). At high levels, fructose-1-phosphate, through lack of branching enzyme activity, another glycogen stor-
similarity in structure to glucose-1-phosphate, inhibits age disease, type IV (Andersen disease). In this case, the
glycogen phosphorylase activity, leading to hypoglyce- glycogen produced is a long, straight chain amylopectin,
mia (glycogen degradation is inhibited when blood glu- which has limited solubility, and precipitates in the liver
cose levels drop). The fructose is derived from the fruit (recall, the liver has the highest concentration of glycogen
juices introduced to the child’s diet. Fructose does not of all tissues). This leads to early liver failure (thus, the
inhibit debranching enzyme, and fructose-6-phosphate high bilirubin and transaminases in the serum) and death
has no effect on glycogen phosphorylase (recall, one of if a liver transplant is not performed. Defects in any of
the products of the glycogen phosphorylase reaction is the other enzymes listed would lead to a different clini-
glucose-1-phosphate, not glucose-6-phosphate). Galac- cal scenario. Lack of glycogen phosphorylase or synthase,
tose is found in lactose, which, while present in milk, is within the liver, would lead to fasting hypoglycemia, but
not found in fruit juice. not liver failure. Lack of these enzymes in the muscle
would lead to exercise intolerance but would not affect
blood glucose levels. Lack of α-glucosidase is Pompe dis-
4 The answer is D: Glucose-6-phosphatase. The child ease, which also leads to an early death, but is due to the
has Von Gierke disease, glycogen storage disease type lack of a lysosomal enzyme, and there is no glycogen pre-
I, a lack of glucose-6-phosphatase. In such a disorder, cipitation within the body of the liver. A lack of debranch-
glucose-6-phosphate, whether produced from glycogen ing activity is glycogen storage disease III, but would also
degradation or gluconeogenesis, cannot be dephospho- lead to fasting hypoglycemia, without glycogen precipita-
rylated for glucose export, and the liver cannot main- tion within the liver. A number of the glycogen storage
tain blood glucose levels. The small amount of glucose diseases are summarized in the figure on page 104.

Chap12.indd 103 8/27/2009 1:07:26 PM

 104 Chapter 12

Types of Glycogenoses
Type Glycogenosis Deficient enzyme Biochemical diagnosis Clinical symptoms
1 Hepatorenal g., Gierke glucose-6-phosphatase Normal glycogen; excessive Hypoglycemia, hyperlipemia,
disease amounts in liver and ketosis, hyperuricemia,
kidneys hepatomegaly, dwarfism
2 Generalized, malignant g.; ␣-1,4-glucosidase Normal glycogen, excessive in all Muscle hypotonia, heart
Pompe disease; organs failure, neurologic
cardiomegalia glycogenica symptoms, infant death
3 Hepatomuscular, benign g.; Amylo-1,6-glucosidase Abnormal glycogen, with short Hepatomegaly, hypoglycemia;
Cori disease, Forbes disease outer chains, in liver and mild course of disease
(with subvariants 3b through f) (more rarely) in muscles
4 Liver, cirrhotic, reticuloendothelial g.; ␣-1,4-glucan: Abnormal glycogen, with long Cirrhosis of the liver;
Anderson disease; amylopectinosis ␣-1,4-glucan- outer chains, in liver, spleen, hepatosplenomegaly
6-glycosyltransferase and lymph nodes
5 Muscular g., Mcardle-Schmid-Pearson ␣-glucanphosphorylase Normal glycogen, excessive Generalized myasthenia and
disease of the muscle amounts in muscle myalgia, myoglobinuria
6 Hepatic g., Hers disease ␣-glucanphosphorylase | Normal glycogen, excessive Hepatomegaly, relatively benign
of the liver amounts in liver
7 Muscular g.; Tarui disease Phosphofructokinase Normal glycogen, in the skeletal Muscle cramping,
of the muscle muscle myoglobinuria
8 Hepatic g.; X-chromosome Phosphorylase-b kinase Normal glycogen, in the liver Clinically mild manifestation,
inheritance of the liver hepatomegaly, hypoglycemia

Answer 5: A summary of the glycogen storage diseases.

6 The answer is C: Adenylate cyclase. If adenylate cyclase phosphorylase molecule can release 100 glucose residues
is defective, glucagon cannot initiate the activation of per second from glycogen, and since there are 10,000
glycogenolysis and inhibition of glycolysis in the liver active phosphorylase molecules, 1,000,000 molecules of
(cAMP levels will not increase, and PKA will stay inac- glucose are released per second once a single molecule
tive). Under such conditions, only the allosteric effec- of PKA has been activated. This is an example of cascade
tors in liver will be active, and there is no activator of amplification, in which an increase in activity of just one
glycogen phosphorylase b. When the hypoglycemia is molecule at the top of the cascade can result in a large
severe enough, epinephrine release, working through response further down the cascade.
its α-receptors, will activate phospholipase C, leading
to calcium release. The increased calcium can activate 8 The answer is B: Increase in sarcoplasmic calcium
phosphorylase kinase, which will activate phosphory- levels. When the individual begins to run away from
lase, but fasting hypoglycemia will still occur. Defects in the alligator, muscle contraction leads to calcium release
liver PFK-1 or glucokinase will not affect glycogenoly- from the sarcoplasmic reticulum to the sarcoplasm. This
sis or gluconeogenesis. Defects in liver galactokinase or increase in sarcoplasmic calcium binds to the calmodulin
fructokinase will not allow for metabolism of galactose subunit of phosphorylase kinase and activates the enzyme
or fructose, but do not affect the ability of the liver to in an allosteric manner, in the absence of any covalent
degrade glycogen, or perform gluconeogenesis from modification. The activated phosphorylase kinase will
other precursors. phosphorylate and activate glycogen phosphorylase,
which will initiate glycogen degradation. When epi-
7 The answer is E: 1,000,000. One active PKA can acti- nephrine reaches the muscle, phosphorylase kinase will
vate in 1 s 100 molecules of phosphorylase kinase. Each be fully activated via phosphorylation by PKA. The acti-
phosphorylase kinase can, in 1 s activate 100 molecules vation of glycogen degradation under these conditions
of glycogen phosphorylase (so at this point we have is not due to a decrease in blood glucose levels, insu-
100 times 100 active molecules of phosphorylase, or lin binding (insulin would not be released under these
10,000 active phosphorylase molecules). Each active conditions), a decline in ATP levels (the AMP-activated

Chap12.indd 104 8/27/2009 1:07:26 PM

 Glycogen Metabolism 105
Extracellular

+
Cell membrane

+ Cytoplasm

Muscle contraction
P
Answer 8: Regulation of glycogen Ca2+ + Calmodulin- Glycogen synthase
P
synthesis and degradation by cal- dependent (inactive)
P
protein kinase
cium in the muscle. Muscle con- Glycogen synthase
traction leads to calcium release (active)
Sarcoplasmic Ca2+-calmodulin
from the sarcoplasmic reticulum, reticulum Glycogen
which binds to calmodulin, acti- phosphorylase a
Phosphorylase P
vating phosphorylase kinase, and (active)
+
kinase
leading to the inhibition of glyco- Glycogen
gen synthesis and the activation phosphorylase b
of glycogen degradation. (inactive)

protein kinase does not activate glycogen degradation), shown in the figure below, there are many glycogen
or lactate production, the end product of anaerobic particles present in the muscle cells just below the sar-
metabolism. The figure above shows the stimulation colemma, as the glycogen is not able to be degraded.
of glycogen degradation, working through calcium Muscle damage also results from vigorous exercise,
activation of the calmodulin subunit of phosphorylase releasing myoglobin into the circulation, which is what
kinase. leads to the reddish-brown urine after exercise. Altera-
tions in liver enzymes (phosphorylase or PFK-1) would
9 The answer is D: Increase in intracellular AMP levels. As not affect exercise tolerance in the muscle. Muscle does
AMP levels increase in the muscle due to the need for not contain glucose-6-phosphatase, and this problem
ATP for muscle contraction, and the activity of the ade- is not due to a lack of muscle GLUT4 transporters,
nylate kinase reaction, the AMP-activated protein kinase as the muscle cannot utilize stored, internal glucose
is turned on. One of the effects of the AMP-activated supplies.
protein kinase is to increase the number of GLUT4
transporters in the muscle membrane, in a process simi-
lar to the action of insulin. This enables muscle to take
up glucose efficiently from the circulation when inter-
nal energy levels are low. The ability of the muscle to
take up glucose under these conditions is not due to an
increase in epinephrine levels, an increase in sarcoplas-
mic calcium levels, or insulin binding to muscle cells.
Under conditions as described in the question, insu-
lin will not be present in the circulation to bind to the
muscle cells. As the muscle does not contain glucagon
receptors, there is no effect on muscle when glucagon is
present in the circulation.

10 The answer is A: Muscle glycogen phosphorylase. The

patient is lacking muscle glycogen phosphorylase The electron micrograph demonstrates an abnormal mass of gly-
and cannot utilize muscle glycogen for energy. This cogen (not surrounded by a membrane) particles just beneath the
is another glycogen storage disease, type V, McArdle sarcolemma, which distinguishes this disorder from Pompe disease
disease. The lack of muscle glycogen phosphorylase is (a lysosomal disorder in which glycogen within the lysosomes cannot
why lactate production during exercise is very low. As be degraded).

Chap12.indd 105 8/27/2009 1:07:27 PM

 106 Chapter 12

11 The answer is D: Stimulation of glycogen synthase D. Gly- activate glycogen phosphorylase b; the allosteric activa-
cogen synthase D (the inactive, phosphorylated form) can tor is specific for AMP. The table below summarizes the
be allosterically activated by glucose-6-phosphate bind- allosteric interactions involved in glycogen metabolism.
ing to the enzyme. Glucose-6-phosphate will inhibit the
AMP-stimulation of muscle phosphorylase b, but does Form of enzyme Tissue Activator Inhibitor
not have any allosteric effect on the other enzymes listed Liver Already active Glucose
Phosphorylase a
(PFK-1, glucose-6-phosphatase, or GLUT4 transporters) Muscle Already active Creatine-
as answer choices for this problem. phosphate
Liver None None
Phosphorylase b
12 The answer is B: Lactate inhibition of kidney tubule Muscle AMP ATP, G6P
absorption of urate. Patients with von Gierke disease
display elevated levels of lactate, which interferes with Phosphorylase Liver and Ca2+ None
kinase b Muscle
the kidney’s ability to remove uric acid from the blood
and place it in the urine. This leads to hyperuricemia. The Glycogen Liver and Glucose-6- None
reason lactate levels are elevated is that the high glucose- synthase D Muscle phosphate
6-phosphate in the cell (recall, the defect in this disorder
is a lack of glucose-6-phosphatase activity) forces glyco-
lysis forward, producing pyruvate, which is converted to 15 The answer is D: An altered glycogenin with an
lactate in order to regenerate NAD+ to allow glycolysis to increased Km for UDPglucose. A reduction in over-
continue. Glucose-6-phosphate does not inhibit glucose- all glycogen synthesis suggests that the biosynthetic
6-phosphate dehydrogenase (that enzyme is regulated pathway is defective in some step. All glycogen
by the NADP+ levels), nor does it regulate a committed molecules have, at their core, a glycogenin protein
step of de novo purine synthesis, amidophosphoribosyl molecule, which autocatalyzes the addition of six
transferase (which is regulated by adenine and guanine glucose residues, using UDPglucose as the carbohy-
nucleotides). Glucose-6-phosphate does stimulate glyco- drate donor. This structure then provides the initial
gen synthase D, but that activation does not play a role primer required by glycogen synthase. If the Km for
in elevated urate levels. Glucose-6-phosphate does not UDPglucose is increased, the rate of formation of gly-
affect urate absorption within the kidney. cogen primers will be decreased, as the levels of UDP-
glucose may not be sufficient to allow glycogenin to
13 The answer is C: Phosphorylase a. The glucose in the self-prime. This would result in an overall reduction of
sports drink will bind to liver glycogen phosphorylase a glycogen levels within the cell. If a glycogen synthase
and inhibit its activity allosterically. Once the insulin sig- had a reduced Km for UDPglucose, then the enzyme
nal reaches the liver, phosphorylase a will be converted would be active at lower UDPglucose levels, and one
to the dephosphorylated phosphorylase b by activated would expect greater than normal glycogen synthesis.
phosphatases. There is no allosteric inhibitor for glyco- Phosphorylase kinase has as its substrate phosphory-
gen synthase I, or protein phosphatase 1 (which is regu- lase, not glycogen, so answer B is not correct. If the
lated by protein inhibitor 1). Adenylate kinase is not uridyl transferase had a reduced Km for a substrate,
regulated allosterically, and there is no allosteric inhibi- it would proceed at low substrate levels and would
tor of phosphorylase kinase a (the nonphosphorylated not give the resultant phenotype. And, if phosphory-
form can be activated by calcium). lase kinase had an increased Km for glycogen synthase,
then glycogen synthase would not be inactivated as
14 The answer is D: Increase in intracellular AMP. AMP
rapidly, and glycogen synthesis would be expected to
will activate muscle glycogen phosphorylase b allosteri-
continue under conditions where it should not, lead-
cally, allowing glycogen degradation to begin before any
ing to enhanced glycogen synthesis.
hormonal signal has reached the muscle. The addition
of epinephrine to the muscle requires activation of
adenylate cyclase to initiate glycogen degradation, and 16 The answer is E. Under fasting conditions, the liver
adenylate cyclase has been inactivated in this cell line. is exporting glucose, so the pathways of glycogenoly-
Muscle lacks glucagon receptors, so cannot respond to sis and gluconeogenesis will be active, while glycolysis
this hormone. An increase in intracellular calcium would will be inhibited (all due to the effects of glucagon and
lead to glycogen degradation (via activation of phos- activation of PKA). In glycolysis, PFK-2 is phosphory-
phorylase kinase b), but magnesium does not have the lated, activating its phosphatase activity, which leads to
same effect as calcium. Increases in ADP levels will not a reduction in fructose-2,6-bisphosphate levels. This

Chap12.indd 106 8/27/2009 1:07:28 PM

 Glycogen Metabolism 107
results in a reduction of PFK-1 activity (thus, PFK-1 is uridyl transferase. Patients cannot metabolize galactose,
not active, but is not phosphorylated). Glycogen degra- and the accumulating galactose-1-phosphate interferes
dation has been activated, and synthesis inhibited, via with glycogen degradation. Nonclassical galactosemia
the phosphorylation of glycogen synthase, inactivat- (type 2) is a deficit in galactokinase, such that galactose
ing the enzyme (thus, glycogen synthase is not active, cannot be phosphorylated. The complications in type
but is phosphorylated). Phosphorylase kinase has been 1 galactosemia due to the accumulation of galactose-1-
activated, and phosphorylated, by PKA (so phospho- phosphate are not seen in type 2 galactosemia. In either
rylase kinase is active, and phosphorylated). Pyruvate case, the missing enzymes are not required for the syn-
dehydrogenase is inactive under these conditions (due thesis of lactose. See the figure below for both the path-
to fatty acid oxidation in the mitochondria acetyl-CoA way of lactose synthesis, and the defects in classical and
levels and NADH levels are high, which slows down the nonclassical galactosemia.
TCA cycle and inhibits pyruvate dehydrogenase), and
it is also phosphorylated by the PDH-kinase, which is
activated by NADH. 18 The answer is A: One high-energy bond. For a mole-
cule of glucose-6-phosphate (G6P) to be incorporated
17 The answer is B: Phosphoglucomutase. For this woman into glycogen, the following pathway must be utilized:
to synthesize lactose, she needs to synthesize the pre- G6P is converted to glucose-1-phosphate (G1P) via
cursors UDPgalactose and glucose, both of which phosphoglucomutase, the G1P reacts with UTP to form
are available from glucose. Glucose is converted to UDPglucose via glucose-1-phosphate uridyl transferase,
glucose-6-phosphate by hexokinase in the breast, releasing pyrophosphate. The resultant pyrophosphate
and then phosphoglucomutase will convert this to is hydrolyzed to two inorganic phosphates, with the loss
glucose-1-phosphate (G1P). The G1P will react with of one high-energy bond. The UDPglucose then reacts
UTP in the glucose-1-phosphate uridyl transferase with glycogen to produce a glycogen chain with one
reaction, producing UDPglucose. The C4 epimerase additional sugar, and UDP is released. The overall equa-
will then produce UDPgalactose from UDPglucose. The tion for these steps is: G6P + UTP + glycogenn yields
UDPgalactose then condenses with free glucose (using UDP + 2Pi + (glycogen)n+1. These steps are outlined
lactose synthase) to produce lactose and UDP. The other below:
enzymes listed as answers are not required to produce
lactose from the single precursor glucose. Fructokinase Gluose-6-phosphate → Glucose-1-phosphate
is unique for fructose metabolism. Aldolase is a glyco- Glucose-1-phosphate + UTP → UDPglucose + PPi
lytic enzyme, which is deficient in hereditary fructose PPi + H2O → 2 Pi
intolerance. Phosphohexose isomerase coverts glucose- UDPglucose + glycogenn → Glycogenn+1 + UDP
6-phosphate to fructose-6-phosphate, which is not UDP + ATP → UTP + ADP
required for lactose synthesis. Classical galactosemia Sum: Glucose-6-phosphate + ATP
(severe, type 1) is a deficit of galactose-1-phosphate + glycogenn + H2O → glycogenn+1 + ADP + 2Pi

Glucose-1-P Galactose Nonclassical galactosemia

UTP ATP Classical galactosemia
galactokinase
PPi ADP
UDPGlucose Galactose-1-P
galactose-1-P
epimerase
UDP uridylyltransferase
Glucose Glucose-1-P
UDPGalactose
D-Glucose UDP
lactose synthase epimerase
(galactosyltransferase (acceptor) Galactose
+ α-lactalbumin) Glucose-6-P Glycolysis
UDP
(other tissues)
(Liver)
Lactose
CH2OH CH2OH Glucose
HO O O OH
OH O OH

OH OH

Answer 17

Chap12.indd 107 8/27/2009 1:07:29 PM

 108 Chapter 12

Glucose-6-phosphate Glucose-1-phosphate

Fructose-6-phosphate UDPGlucose

Pi
fructose-1,6-bisphosphatase
Glycogen

Fructose-1,6-bisphosphate

Dihydroxyacetone-P Glyceraldehyde-3-P
Glyceraldehyde-3-phosphate
dehydrogenase
Glycerol Glycerol-3-P 1,3-bisphosphoglycerate

Phosphoenolpyruvate
phosphoenolpyruvate
carboxykinase
TCA
Amino Oxaloacetate Amino
cycle
acids acids
Alanine
Pyruvate
carboxylase Pyruvate

Lactate

Answer 19

19 The answer is A: a-ketoglutarate dehydrogenase. In other sources for energy to continue running. In the
order for citrate to be converted to glycogen, the citrate vernacular of the sport, when all the glycogen stores
must first be converted to oxaloacetate in the TCA cycle are exhausted, the runner “hits the wall.” This is usu-
(which requires the participation of α-ketoglutarate ally somewhere around mile 20. Research has shown
dehydrogenase). From oxaloacetate, PEP carboxyki- that proper “carb loading” prior to a race can increase
nase will convert this to PEP, which will go through body stores of glycogen and increase performance.
the gluconeogenic pathway up to glucose-6-phosphate. Though it is a small increase (1% to 2%), it has been
From there, G1P is produced, then UDPglucose, and documented repeatedly in research studies even in
finally incorporation of the glucose into glycogen. Pyru- highly trained athletes. Therefore, it is not a myth.
vate carboxylase, while being a gluconeogenic enzyme, To properly carbohydrate load, one must deplete gly-
converts pyruvate to OAA, which is not required in cogen stores with very vigorous exercise about 2 to
this series of reactions. PFK-1 and pyruvate kinase are 3 days prior to a race. This stimulates glycogen syn-
irreversible enzymes of glycolysis and are not used in thase which increases glycogen stores over the next
the gluconeogenic pathway. Glucose-6-phosphatase 2 to 3 days before it returns to baseline levels. This
removes the phosphate from G6P, which is not required is a critical step in the process of “overbuilding” gly-
when glycogen is being synthesized. See the figure cogen stores. This is the step the patient is not doing
above for the pathways. properly. Vigorous exercise cannot then be continued
during the 2 to 3 days of glycogen building or the
20 The answer is B: He is not depleting glycogen stores glycogen stores will be utilized. Pancakes, potatoes,
prior to loading. Marathon runners deplete their brown rice, and pasta are excellent sources of simple
stores of glycogen during a race and need to catabolize carbohydrates.

Chap12.indd 108 8/27/2009 1:07:30 PM

 Chapter 13

Fatty Acid
Metabolism
This chapter examines the students’ ability to (A) Carnitine acyltransferase I
integrate their knowledge of fatty acid metabolism (B) Carnitine acyltransferase II
with clinical problems and carbohydrate (C) Acyl-CoA dehydrogenase
metabolism. (D) Enoyl-CoA dehydrogenase
(E) β-keto thiolase
QUESTIONS 5 A 3-month-old child had her first ear infection and was
Select the single best answer. feeding poorly due to the ear pain. One morning the parents
found the child in a nonresponsive state and rushed her
1 You prescribe ibuprofen to help reduce your patient’s to the emergency department. A blood glucose level was
inflammation. Which of the following pathways is 45 mg/dL, and upon receiving intravenous glucose the child
blocked as an anti-inflammatory mechanism of action became responsive. Further blood analysis displayed the
of nonsteroidal anti-inflammatory drugs? absence of ketone bodies, normal levels of acyl-carnitine,
(A) Prostaglandin synthesis and the presence of the following unusual carboxylic acids
(B) Thromboxane synthesis shown below. The enzymatic defect in this child is most
(C) Leukotriene synthesis likely in which of the following enzymes?
(D) All eicosanoid synthesis
(E) Arachidonic acid release from the membrane O– O–
C CH2 CH2 CH2 CH2 C
O O
2 You have an asthmatic patient who is already on an
inhaled steroid and albuterol, but is still having diffi- O– O–
culty. You add montelukast to her regimen. Montelukast C CH2 CH2 CH2 CH2 CH2 CH2 C
O O
(Singulair) specifically blocks the product of which of
the following metabolic pathways?
(A) Fatty acyl-CoA synthetase
(A) Cyclooxygenase
(B) Carnitine translocase
(B) Lipoxygenase
(C) Carnitine acyltransferase I
(C) P450
(D) Carnitine acyltransferase II
(D) Cori cycle
(E) Medium chain acyl-CoA dehydrogenase
(E) TCA cycle
6 Regarding the child described in question 5, why were
3 Coconut palm tress cannot survive growing outdoors in
fasting blood glucose levels so low?
Kansas. Which of the following is the best explanation
(A) Acyl-carnitine inhibition of gluconeogenesis
for this finding?
(B) Dicarboxylic acid inhibition of gluconeogenesis
(A) Coconut/palm oil is a saturated fat
(C) Insufficient energy for gluconeogenesis
(B) Coconut/palm oil is a monounsaturated fat
(D) Dicarboxylic acid inhibition of glycogen phospho-
(C) Coconut/palm oil is a polyunsaturated fat
rylase
(D) Kansas soil is not sandy enough to support growth
(E) Reduction of red blood cell production of lactate for
(E) Kansas soil is too rocky to support growth
gluconeogenesis
4 An inactivating mutation in the ETF:CoQ oxidoreductase 7 A 6-month-old child presents to the physician in a hypo-
will lead to an initial inhibition of which of the follow- tonic state. The child has previously had a number of
ing enzymes in fatty acid oxidation? hypoglycemic episodes, at which times blood glucose

109

Chap13.indd 109 10/28/2010 3:49:24 PM

 110 Chapter 13

levels were between 25 and 50 mg/dl. Blood work shows 12 A mouse model has been generated as an in vivo system
normal levels of ketone bodies (not elevated) during for studying fatty acid synthesis. An inactivating muta-
hypoglycemic episodes. Carnitine levels in the blood tion was created which led to the cessation of fatty acid
were, however, below normal. Free fatty acid levels were synthesis and death to the mice. This mutation is most
elevated in the blood, however acyl-carnitine levels were likely in which of the following proteins?
normal. Dicarboxylic acid levels were non-detectable in
(A) Carnitine acyl transferase I
the blood. A liver biopsy shows elevated levels of triglycer-
(B) Carnitine acyl transferase II
ide. A likely enzymatic defect is which of the following?
(C) Citrate translocase
(A) Carnitine acyltransferase I
(D) Glucose-6-phosphate dehydrogenase
(B) Carnitine acyltransferase II
(E) Medium chain acyl-CoA dehydrogenase
(C) Medium chain acyl-CoA dehydrogenase
(D) Hormone sensitive lipase
13 α-oxidation would be required for the complete oxida-
(E) Carnitine transporter tion of which of the following fatty acids?

8 Carnitine deficiency can occur in a number of ways. Sec-

ondary carnitine deficiency can be distinguished from CH3
O
primary carnitine deficiency by measuring which of the
A CH3 (CH2)n C CH2 CH2 C
following in the blood? O–
H
(A) Fatty acids
(B) Acyl-carnitine
(C) Lactic acid
CH3
(D) Glucose O
(E) Ketone bodies B CH3 (CH2)n CH2 C CH2 C
O–
H
9 Which one of the following fatty acids will generate
the largest amount of ATP upon complete oxidation to
CH3
carbon dioxide and water? O
(A) C16:0 C CH3 (CH2)n CH2 CH2 C C
(B) cisΔ9 C16:1 O–
H
(C) cisΔ9 C18:1
(D) cisΔ6 C18:1 CH3
(E) cisΔ9, Δ12 C18:2 CH2 O

10 An individual contains an inactivating mutation in a D CH3 (CH2)n C CH2 CH2 C

O–
particular muscle protein, which leads to weight loss H
due to unregulated muscle fatty acid oxidation. Such an
inactivated protein could be which of the following?
CH3 CH3
(A) Malonyl-CoA decarboxylase O
(B) Carnitine acyl transferase I E CH3 (CH2)n C CH2 C C
(C) Carnitine acyl transferase II O–
H H
(D) Medium chain acyl-CoA dehydrogenase
(E) Acetyl-CoA carboxylase 2
14 A 2-month-old infant with failure to thrive displays
11 The net energy yield obtained (moles of ATP per mole hepatomegaly, high levels of iron and copper in the
of substrate oxidized) when acetoacetate is utilized by blood, and vision problems. This child has difficulty in
the nervous system as an alternative energy source is carrying out which of the following types of reactions?
which of the following? Consider that acetoacetate must (A) Oxidation of very long chain fatty acids
be oxidized to four molecules of carbon dioxide during (B) Synthesis of unsaturated fatty acids
the reaction sequence. (C) Oxidation of acetyl-CoA
(A) 17 (D) Oxidation of glucose
(B) 18 (E) Synthesis of triacylgycerol
(C) 19
(D) 20 15 A 55-year-old man had been advised by his physician
(E) 21 to take 81 mg of aspirin per day to reduce the risk of

Chap13.indd 110 10/28/2010 3:49:25 PM

 Fatty Acid Metabolism 111
blood clots leading to a heart attack. The rationale for 18 An individual with a biotinidase deficiency was shown
this treatment is which of the following? to produce fatty acids at a greatly reduced rate (in the
(A) To reduce prostaglandin synthesis absence of supplements) as compared to someone who
(B) To reduce leukotriene synthesis did not have the deficiency. This is due to which of the
(C) To reduce thromboxane synthesis following?
(D) To increase prostacyclin synthesis (A) Low activity of citrate lyase
(E) To increase Lipoxin synthesis (B) Reduced activity of malic enzyme
(C) Reduced activity of acetyl transacylase
16 You are examining a patient who exhibits fasting hypogly- (D) Defective acyl carrier protein
cemia and need to decide between a carnitine deficiency (E) Reduced ability to form malonyl-CoA
and a carnitine acyltransferase 2 deficiency as the pos-
sible cause. You order a blood test to specifically examine
the levels of which one of the following? 19 Liver fatty acid oxidation leads to an enhancement of
(A) Glucose gluconeogenesis via which of the following?
(A) Generation of precursors for glucose synthesis
(B) Ketone bodies
(B) Activation of pyruvate carboxylase
(C) Insulin
(C) Activation of phosphoenolpyruvate carboxykinase
(D) Acyl-carnitine
(D) Inhibition of pyruvate kinase
(E) Carnitine
(E) Inhibition of PFK-2
17 Inhibitors specific for cyclooxygenase 2 (COX-2) were
deemed more efficacious for certain conditions than 20 A 35-year-old man in New York city, originally from
inhibitors which blocked both COX-1 and COX-2 Jamaica, purchased an illegally imported fruit from a
activities. This is due to which of the following? street vendor and, within 4 h of eating the fruit, began
(A) Inhibiting COX-1 increased the frequency of heart vomiting severely. When brought to the emergency
attacks department the man was severely dehydrated and exhib-
(B) Inhibiting COX-2 did not alter prostaglandin pro- ited several seizures. The toxic effects of the fruit were
duction interfering with which of the following?
(C) COX-2 is specifically induced during inflammation (A) Fatty acid release from the adipocyte
(D) Specifically inhibiting COX-2 reduces the rate of (B) Fatty acid entry into the liver cell
heart attacks (C) Fatty acid activation
(E) COX-1 is inducible and only expressed during wound (D) Fatty acid transport into the mitochondria
repair, while COX-2 is expressed constitutively (E) Oxidative phosphorylation

Chap13.indd 111 8/27/2009 12:39:01 PM

 112 Chapter 13

ANSWERS from the membrane (which would block all eicosanoid

synthesis); however, they do interfere with the cyclooxy-
1 The answer is A: Prostaglandin synthesis. Eicosanoids genase pathway. Prostaglandins affect inflammation,
are potent regulators of cellular function. They are derived thromboxanes affect formation of blood clots, and
from arachidonic acid and are metabolized by three leukotrienes affect bronchoconstriction and bronchodi-
pathways: the cyclooxygenase pathway (prostaglandins latation. NSAIDs block prostaglandins as one of their
and thromboxanes), lipoxygenase pathway (leukot- anti-inflammatory mechanisms. Thus, while NSAIDS
rienes), and the cytochrome P450 pathway (epoxides) will block both prostaglandin and thromboxane synthe-
(see the figure below). Nonsteroidal anti-inflammatory sis, it is the blockage of prostaglandin synthesis which
drugs (NSAIDs) do not block arachidonic acid release will block the inflammatory symptoms.

Arachidonic acid

Cyclooxygenase Lipoxygenase Cytochrome P450

PGG2 HPETE Epoxides

Prostaglandins Thromboxanes Leukotrienes HETE Lipoxins diHETE HETE

2 The answer is B: Lipoxygenase. Montelukast is a carbon–carbon double bond between carbons 2 and 3
leukotriene blocker. Leukotrienes are formed through of the fatty acyl-CoA, generating an FADH2 in the pro-
the lipoxygenase pathway and affect bronchoconstric- cess. The FADH2 then donates its electrons to the electron
tion and allergy pathways (see the figure in answer to transfer flavoprotein (ETF), which then transfers the elec-
question 1). The cyclooxygenase pathway produces trons to coenzyme Q (via the ETF:CoQ oxidoreductase).
prostaglandins and thromboxanes. The P450 pathway A lack of the oxidoreductase activity will lead to an
produces epoxides. The Cori cycle is related to gluco- accumulation of mitochondrial FADH2, depleting FAD
neogenesis (lactate transfer from the muscle to the liver), levels, and reducing the activity of the acyl-CoA dehy-
while the TCA cycle is utilized to oxidize acetyl-CoA to drogenases. The lack of FAD does not directly inhibit the
CO2 and H2O. β-ketothiolase or enoyl-CoA dehydrogenase steps, nor
does it affect the activity of the carnitine acyltransferases.
3 The answer is A: Coconut/palm oil is a saturated fat. The figure below shows the normal transport of elec-
Saturated fats do not liquefy until a much higher tem- trons from FADH2 to coenzyme Q when the FADH2 is
perature than that at which monounsaturated or polyun- generated by the acyl-CoA dehydrogenases.
saturated fats do (the melting temperature for saturated
fats is greater than that for unsaturated fats). Conversely,
H H
saturated fats are solids at a higher temperature than CH2 CH2 C C
unsaturated fats and cannot exist in a liquid form at a Palmitoyl CoA Palmitoloyl CoA
lower temperature. Since the oil of a plant is its “lifeblood,”
at a lower temperature, a saturated oil would solidify and
the plant would die. Saturated oil plants cannot survive in
FAD FAD (2H)
a temperate climate (Kansas) and need a tropical climate Acyl CoA DH Acyl CoA DH
of warm temperatures all year round. Only polyunsatu-
rated oil plants can survive in a temperate climate (corn,
flax, wheat, and canola). Monounsaturated oils need a
FAD (2H) FAD
warmer climate, but not as warm as the tropics (olive, ETF ETF
peanut). Knowing where a plant grows gives a large clue
as to whether the oil will be saturated, monounsaturated,
or polyunsaturated. The difference in oil content between
FAD FAD (2H)
plants appears to be an evolutionary process. Kansas soil ETF • QO ETF • QO
is very rich and supports growth of most plants.

4 The answer is C: acyl-CoA dehydrogenase. The acyl- CoQH2 CoQ

CoA dehydrogenases catalyze the first step of the fatty
acid oxidation spiral in that these enzymes create a Electron-transport chain

Chap13.indd 112 8/27/2009 12:39:01 PM

 Fatty Acid Metabolism 113

5 The answer is E: Medium chain acyl-CoA dehydrogenase. 7 The answer is E: Carnitine transporter. The child has a
The child has MCAD (medium-chain acyl-CoA dehy- mutation in the enzyme which transports carnitine into
drogenase) deficiency, an inability to completely oxi- liver and muscle cells, leading to a primary carnitine
dize fatty acids to carbon dioxide and water. With an deficiency. The carnitine stays in the blood and is even-
MCAD deficiency, gluconeogenesis is impaired due to a tually lost in the urine (the same carnitine transporter
lack of energy from fatty acid oxidation, and an inabil- is required to recover the carnitine from the urine in
ity to fully activate pyruvate carboxylase, as acetyl-CoA the kidney). Since the liver is carnitine deficient, ketone
activates pyruvate carboxylase, and acetyl-CoA pro- body production is minimal at all times, even during a
duction from fatty acid oxidation is greatly reduced. fast (thus, the lack of baseline ketone bodies in the cir-
In an attempt to generate more energy, medium-chain culation under these conditions). Fatty acids will rise in
fatty acids are oxidized at the ω ends to generate circulation, as they cannot be stored in the cells as acyl-
the dicarboxylic acids seen in the question (see the CoA. The liver shows evidence of triglyceride formation
figure below for an overview of ω oxidation). The as the acyl-CoA cannot be degraded, and acyl-CoA accu-
finding of such metabolites (dicarboxylic acids) in mulates within the cytoplasm, leading to triglyceride
the blood is diagnostic for MCAD deficiency. If there formation. A defect in carnitine acyl transferase 1 would
were mutations in any aspect of carnitine metabolism, lead to elevated levels of carnitine in the circulation. A
there would be no oxidation of fatty acids (the fatty defect in carnitine acyltransferase II would lead to ele-
acids would not be able to enter the mitochondria), vated levels of acyl-carnitine in the circulation (since the
and the dicarboxylic acids (which are byproducts of acyl group cannot be removed from the carnitine). The
fatty acid metabolism) would not be observed. Simi- lack of circulating dicarboxylic acids indicates that the
larly, a mutation in the fatty acyl-CoA synthetase (the defect is not in MCAD (medium-chain acyl-CoA dehy-
activating enzyme, converting a free fatty acid to an drogenase). A defect in hormone sensitive lipase would
acyl-CoA) would also result in a lack of fatty acid oxi- show a decrease in free fatty acid levels, rather than the
dation, as fatty acids are not able to enter the mito- increase observed in the patient.
chondria in their free (nonactivated) form.
8 The answer is B: acyl-carnitine. Primary carnitine defi-
O ciency is a lack of carnitine within the cell (such as a
mutation in the carnitine transporter); secondary carni-
CH3 (CH2)n C O–
tine deficiency occurs when the carnitine is sequestered
ω
in the form of acyl-carnitine (the carnitine cannot be
O
removed from the acyl group, such as a defect in car-
nitine acyl transferase 2). Thus, elevated levels of acyl-
HO CH2 (CH2)n C O–
carnitine would be expected in a secondary carnitine
deficiency, but not in a primary carnitine deficiency.
In both types of carnitine deficiencies, fatty acid oxi-
dation is significantly reduced, so the levels of ketone
bodies, glucose, lactate, and fatty acids would be similar
O O
under both conditions.
–
O C (CH2)n C O–

9 The answer is C: cisD9 C18:1. An 18-carbon fatty acid

will generate an additional acetyl-CoA, one NADH, and
6 The answer is C: Insufficient energy for gluconeogenesis. one FADH2 as compared to a 16-carbon fatty acid. Thus,
Defects in fatty acid oxidation deprive the liver of energy the addition of two carbons will add 14 additional ATP
when fatty acids are the major energy source (such as to the overall energy yield (10 ATP per acetyl-CoA, 2.5
during exercise, or a fast). Because of this, there is insuf- for NADH, and 1.5 for FADH2). An unsaturation at an
ficient energy to synthesize glucose from gluconeogenic odd carbon position will require the use of an isomerase
precursors (it requires 6 moles of ATP to convert 2 during oxidation, and this will result in the loss of gen-
moles of pyruvate to 1 mole of glucose). Acyl-carnitines eration of 1 FADH2; an unsaturation at an even carbon
and dicarboxylic acids have no effect on the enzymes of position will require the use of the 2,4 dienoyl-CoA
gluconeogenesis, nor do they hinder the ability of the reductase, and this will result in the loss of generation
red blood cell to utilize glucose through the glycolytic of 1 NADPH. Thus, an unsaturation at an odd position
pathway. Additionally, acetyl-CoA levels are low due to results in the loss of 1.5 ATP, while an unsaturation at
the lack of complete fatty acid oxidation and pyruvate an even position results in the loss of 2.5 ATP. Thus,
carboxylase, a key gluconeogenic enzyme, is not fully in comparing two 18-carbon fatty acids, one with an
activated. This also contributes to the reduced gluco- unsaturation at position 9, and the other at position 6,
neogenesis observed in patients with MCAD defective. the fatty acid with the double bond at position 9 will

Chap13.indd 113 10/28/2010 3:49:28 PM

 114 Chapter 13

A B
12 9 Linoleolyl CoA
1
O
Mitochondrial O 18
C cis–Δ9, cis–Δ12
matrix β α
CH3 CH2 CH2 CH2 C~ SCoA Fatty SCoA
[total C=n] acyl CoA β oxidation
FAD (three spirals) 3 Acetyl CoA
1
acyl CoA
dehydrogenase
FAD (2H) ~1.5 ATP 4 3
O
O C cis–Δ3, cis–Δ6
β 2
SCoA
CH3 CH2 CH CH C~ SCoA trans Δ2 Fatty
enoyl CoA enoyl CoA
isomerase
H2O
2
enoyl CoA 4 2
1 SCoA
hydratase
C trans–Δ2, cis–Δ6
3
β-Oxidation O
OH O
β One spiral of
Spiral
CH3 CH2 CH CH2 C~ SCoA L-β-Hydroxy β oxidation
Acetyl CoA
acyl CoA and the first step
NAD+ of the second spiral
3 5 4
2
β-hydroxy acyl CoA 1 SCoA
dehydrogenase
NADH + H+ ~2.5 ATP C trans–Δ2, cis–Δ4
3
O
O O
β NADPH + H+
CH3 CH2 C CH2 C~ SCoA β-Keto 2,4-dienoyl CoA
acyl CoA reductase NADP+
CoASH
4
β-keto thiolase 5 3 1 O
C trans–Δ3
4 2 SCoA
O O
CH3 CH2 C ~ SCoA + CH3 C~ SCoA enoyl CoA
isomerase
[total C=(n–2)] Fatty acyl CoA Acetyl CoA

5 3 1 O
C trans–Δ2
4 2 SCoA

β oxidation
(four spirals)

5 Acetyl CoA

Answer 9: Panel A: The steps of β-oxidation. The four steps are repeated until an even-chain fatty acid is completely converted to acetyl-CoA.
The FAD(2H) and NADH are reoxidized by the electron-transport chain, producing ATP. Panel B: The additional reactions required for the oxida-
tion of unsaturated fatty acids. The two new enzymes required are the enoyl-CoA isomerase and the 2,4 dienoyl-CoA reductase.

yield one more ATP than the fatty acid with the unsatu- oxidation is reduced, and as the levels decrease, fatty acid
ration at position 6. An overview of the fatty acid oxi- oxidation will increase. If malonyl-CoA decarboxylase
dation spiral is shown above, along with the reactions were inactivated, malonyl-CoA levels would remain
required for the oxidation of unsaturated fatty acids. elevated, and fatty acid oxidation would be inhibited.
Inactivating mutations in either carnitine acyltransferase
10 The answer is E: acetyl-CoA carboxylase 2. An inactivat- 1 or 2 would lead to an inability to oxidize fatty acids, as
ing mutation in acetyl-CoA carboxylase would lead to an they would not enter the mitochondria. A defect in medi-
inability to produce malonyl-CoA, which regulates fatty um-chain acyl-CoA dehydrogenase (MCAD) would also
acid oxidation through an inhibition of carnitine acyl result in reduced fatty acid oxidation, as the initial step
transferase 1. As malonyl-CoA levels increase, fatty acid of the oxidation spiral would be inhibited once the fatty

Chap13.indd 114 8/27/2009 12:39:03 PM

 Fatty Acid Metabolism 115
acid had been reduced to about 10 carbons in length. produce acetyl-CoA and oxaloacetate. The oxaloacetate
The reactions catalyzed by malonyl-CoA decarboxylase is recycled to pyruvate, producing NADPH in the pro-
and acetyl-CoA carboxylase are shown below. cess, which is also required for fatty acid biosynthesis.
A defect in either carnitine acyl transferase will not affect
O fatty acid biosynthesis, as those enzymes are required
CH3 C ~ SCoA to transport the fatty acid into the mitochondria for its
Acetyl CoA oxidation. A lack of glucose-6-phosphate dehydroge-
CO2
nase will not interfere with fatty acid synthesis, as malic
CO2 enzyme can provide sufficient NADPH for the pathway.
ATP
Biotin MCAD is involved in fatty acid oxidation and does not
Malonyl CoA acetyl CoA
ADP + Pi affect fatty acid synthesis.
decarboxylase carboxylase

O O 13 The answer is B. α-oxidation leads to the oxidation of

–
O C CH2 C ~ SCoA
the α-carbon of a branched chain fatty acid to gener-
ate an α-keto acid, which undergoes oxidative decar-
Malonyl CoA
boxylation. This reorients the methyl groups on the
branched chain fatty acid such that they are on the
11 The answer is C: 19. Acetoacetate will react with succi- α-carbon, rather than the β-carbon. In this manner, the
nyl-CoA to produce acetoacetyl-CoA and succinate (this methyl groups do not interfere with the β-oxidation
costs 1 GTP, as the succinate thiokinase step is skipped). spiral (if the methyl group were on the β-carbon, a
The acetoacetyl-CoA is converted to two acetyl-CoA, carbonyl group would be unable to form on that car-
each of which can generate 10 ATP when completely bon, which would block further oxidation of the fatty
oxidized (each acetyl-CoA generates 1 GTP, 3 NADH, acid). Answer choices A, C, D, and E are eliminated
and 1 FADH2). The sum, then, is 20 minus the 1 lost in as requiring α-oxidation because, after one round of
the CoA transferase step, for a net yield of 19 ATP. normal β-oxidation, the methyl group (or butyl group)
will be on the α-carbon and would not interfere with
12 The answer is C: Citrate translocase. Citrate translocase the β-oxidation spiral. An overview of α-oxidation is
is required for citrate to exit the mitochondria and enter shown below.
the cytoplasm in order to deliver acetyl-CoA for fatty
acid biosynthesis (see the figure below). Acetyl-CoA,
which is produced exclusively in the mitochondria, has β-Oxidation
no direct path through the inner mitochondrial mem- CH3 CH3 CH3 CH3
brane. However, under conditions conducive to fatty COO–
acid biosynthesis (high energy levels, and allosteric inhi- CH3
bition of the TCA cycle), citrate will accumulate and
leave the mitochondria (see the figure below). Once α-Oxidation
in the cytoplasm, citrate lyase will cleave the citrate to
The figure depicts the oxidation of phytanic acid. A peroxisomal
Glucose α-hydroxylase oxidizes the α-carbon, and its subsequent oxidation
to a carboxyl group releases the carboxyl group as carbon dioxide.
CO2 NADPH
Subsequent spirals of peroxisomal β-oxidation alternately release
NADP+
propionyl and acetyl-CoA.
Pyruvate Malic
enzyme
Malate

Cytosolic NAD+ 14 The answer is A: Oxidation of very long chain fatty acids.
Pyruvate
malate
NADH
The child has Zellweger’s syndrome, an absence of per-
dehydrogenase
oxisomal enzyme activity. Of the pathways listed as
OAA Acetyl CoA Citrate OAA Acetyl CoA answers, only the oxidation of very long chain fatty acids
lyase
is a peroxisomal function. Fatty acid synthesis occurs
ADP + Pi
Citrate Citrate in the cytoplasm. Acetyl-CoA oxidation takes place in
ATP
the mitochondria. Glucose oxidation is a combination
Citrate leaving the mitochondria and delivering acetyl-CoA to the of glycolysis (cytoplasm) and the TCA cycle (mitochon-
cytoplasm for fatty acid synthesis. dria). Triglyceride synthesis occurs in the cytoplasm.

Chap13.indd 115 8/27/2009 12:39:04 PM

 116 Chapter 13

15 The answer is C: To reduce thromboxane synthesis. It is the thromboxane inhibition which reduces the risk
Thromboxane A2 release from platelets is an essential ele- of blood clots. Leukotrienes and lipoxins require the
ment of forming blood clots, and aspirin will block pros- enzyme lipoxygenase, which is not inhibited by aspirin.
taglandin, prostacyclin, and thromboxane synthesis. These pathways are outlined below.

Arachidonic acid

Cyclooxygenase Lipoxygenase Cytochrome P450

PGG2 HPETE Epoxides

Prostaglandins Thromboxanes Leukotrienes HETE Lipoxins diHETE HETE

16 The answer is D: acyl-carnitine. With a carnitine defi- compared to being covalently bound to proteins). The
ciency, fatty acids cannot be added to carnitine, and formation of malonyl-CoA, via acetyl-CoA carboxylase,
acyl-carnitine would not be synthesized. With a car- requires biotin as a required cofactor (see the figure
nitine acyl-transferase 2 deficiency, the fatty acids are below). Citrate lyase, malic enzyme, acetyl transacylase
added to carnitine, but the acyl-carnitine cannot release (an activity of fatty acid synthase) and acyl carrier pro-
the acyl group within the mitochondria. This will lead to tein (another component of fatty acid synthase) do not
an accumulation of acylcarnitine, which will lead to an require biotin for their activity.
accumulation in the circulation. The end result of either
deficiency is a lack of fatty acid oxidation, such that O
ketone body levels would be minimal under both condi- CH3 C ~ SCoA
tions, and blood glucose levels would also be similar in
Acetyl CoA
either condition. Insulin release is not affected by either
deficiency, and carnitine levels, normally low, would not
CO2
be significantly modified in either deficiency. ATP
Biotin
Acetyl CoA
ADP + Pi
17 The answer is C: COX-2 is specifically induced during carboxylase

inflammation. COX-2 is induced during inflammatory

conditions, while COX-1 is constitutively expressed.
O O
Thus, when an injury occurs, and an immune response
–
is mounted at the site of injury, COX-2 is induced in O C CH2 C ~ SCoA
those cells to produce second messengers that play a Malonyl CoA
role in mediating the pain response. Specifically inhib-
iting the COX-2 isozyme will block the production of
those second messengers, without affecting the normal
function of COX-1. Inhibiting COX-1 may reduce the 19 The answer is B: Activation of pyruvate carboxylase.
frequency of heart attacks, and inhibiting COX-2 will Fatty acid oxidation increases the levels of acetyl-CoA
block prostaglandin production via the cylco-oxyge- within the mitochondrial matrix, and acetyl-CoA is a
nase. Recent data suggests that certain drugs that spe- potent activator of pyruvate carboxylase, a key gluco-
cifically block COX-2 have unwanted side effects, such neogenic enzyme (it will convert pyruvate to oxaloac-
as an increase in heart attacks. etate, a necessary first step to bypass the irreversible
pyruvate kinase reaction). Acetyl-CoA cannot be used
to synthesize net glucose, so it is not an effective precur-
18 The answer is E: Reduced ability to form malonyl- sor of glucose production. Acetyl-CoA does not activate
CoA. Biotinidase is required to remove covalently- PEP carboxykinase (that enzyme is transcriptionally
bound biotin from proteins, which is how most of the controlled), nor does it affect pyruvate kinase (a cyto-
biotin in our diet is received. In the absence of bio- plasmic enzyme). PFK-2 is not regulated by acetyl-CoA
tinidase, individuals can become functionally biotin- (phosphorylation by protein kinase A is the key regula-
deficient, due to the lack of free biotin in the body (as tor effect for PFK-2 in the liver).

Chap13.indd 116 8/27/2009 12:39:07 PM

 Fatty Acid Metabolism 117

20 The answer is D: Fatty acid transport into the mitochon- the affected individual, leading to severe hypoglycemia.
dria. The man had eaten the unripe fruit of the ackee Hypoglycin has no effect on fatty acid release from the
tree (from Jamaica). The unripened fruit contains the adipocyte, or fatty acid entry into liver cells. Fatty acid
toxin hypoglycin A, which will interfere with carnitine’s oxidation is not directly inhibited, nor does this toxin
ability to transport acyl-carnitine groups across the directly inhibit the complexes of the electron transport
inner mitochondrial membrane. This leads to a com- chain and the proton-translocating ATPase.
plete shutdown of fatty acid oxidation in all tissues in

Chap13.indd 117 8/27/2009 12:39:08 PM

 Chapter 14
1

HMP Shunt
Protein Structure
and Oxidative
Function
Reactions
This chapter covers questions related to the He dies that night in his sleep. This is due to which of
pentose phosphate shunt pathway and reactions the following?
that generate and protect against radical oxygen (A) Ethanol stimulating barbiturate absorption by the
species. Interactions of this pathway with other stomach
metabolic pathways are also emphasized. (B) Ethanol inhibition of a cytochrome P450 system
(C) Acetaldehyde reacting with the drug, creating a
QUESTIONS toxic compound
(D) Acetyl-CoA production leads to enhanced energy pro-
Select the single best answer.
duction, which synergizes with barbiturate action
1 A 52-year-old man has had bouts of alcohol abuse in (E) Ethanol’s dehydration effect leads to toxic concen-
his past. During his binges, he takes acetaminophen trations of the seizure medication in the blood
to help control some muscle pain. He then gets very
ill (nausea, vomiting, and right upper quadrant pain), 4 A chronic alcoholic presents to the emergency department
and is rushed to the emergency department. A potential with nystagmus, peripheral edema, pulmonary edema,
treatment for this patient’s symptoms is to take which of ataxia, and mental confusion. The physician orders a test
the following? to determine if there is a vitamin deficiency. An enzyme
(A) Aspirin used for such a test can be which of the following?
(B) A mercaptan (A) Transaldolase
(C) Rifampin (B) Aldolase
(D) Iron (C) Transketolase
(E) Vitamin C (D) β-ketothiolase
(E) Acetylcholine synthase
2 A 34-year-old man was prescribed barbiturates 6 months
ago for a seizure disorder. However, with time, the phy-
sician has had to increase his daily dosage to maintain 5 A researcher is studying the HMP shunt pathway in
the same therapeutic drug level. This is due to which of extracts of red blood cells, in the absence of NADP+, and
the following? in which PFK-1 has been chemically inactivated. Which
carbon substrates are required to generate ribose-5-
(A) Downregulation of drug receptors on the cell surface
phosphate in this system?
(B) Decreased absorption of the drug from the stomach
(A) Glucose-6-phosphate and sedoheptulose-7-phos-
(C) Increased synthesis of opposing neurotransmitters
phate
(D) Induction of drug-metabolizing enzymes
(B) Glucose-6-phosphate and glyceraldehyde-3-phosphate
(E) Induction of targeted enzyme synthesis
(C) Fructose-6-phosphate and glyceraldehyde-3-phos-
3 Considering the patient in question 2, one night, phate
the patient consumes a large amount of alcohol. He (D) Fructose-6-phosphate and pyruvate
continues to take his usual dose of seizure medication. (E) Glucose-6-phosphate and pyruvate

118

Chap14.indd 118 8/27/2009 1:10:21 PM

 HMP Shunt and Oxidative Reactions 119

6 Which one of the following is an obligatory intermediate (A) Superoxide

in the conversion of ribose-5-phosphate to glucose- (B) Nitrogen dioxide
6-phosphate? (C) Nitrous oxide
(A) Pyruvate (D) Hydrogen peroxide
(B) 1,3-bisphosphoglycerate (E) Peroxynitrate
(C) Oxaloacetate
(D) Xylulose-5-phosphate 11 A 25-year-old African American male, in good health,
(E) 6-phosphogluconate had read about fava beans in “Silence of the Lambs.”
For dinner one night, the man had liver with fava beans
and a nice Chianti. About 8 h after eating the beans, the
7 A 23-year-old man of Mediterranean descent was
man was tired and weak. Blood work showed hemolytic
recently prescribed ciprofloxacin to treat a urinary tract
anemia. This patient most likely has a defect in regener-
infection. After 2 days on the drug, the patient was feel-
ating which of the following?
ing worse, and weak, and went to the emergency depart-
ment. He was found to have hemolytic anemia. This (A) NADH
most likely resulted due to which of the following? (B) NAD+
(A) Induction of red blood cell cytochrome P450s, lead- (C) Reduced glutathione
ing to membrane damage (D) Oxidized glutathione
(B) Oxidative damage to red blood cell membranes (E) ATP
(C) Drug induced ion pores in the red blood cell
membrane 12 A 52-year-old male complained of sudden onset of left-
(D) Drug induced inhibition of the HMP shunt pathway sided chest pain radiating down his left arm. Rapid
(E) Oxidative damage to bone marrow, interfering with breathing, sweating, and a feeling of doom accompanied
red blood cell production this. He was rushed to the emergency department. An
angiogram revealed 90% occlusion of the left anterior
descending artery (LAD) and no occlusions in any other
8 You are seeing a male patient of African American
artery. The LAD was opened by angioplasty. However,
descent, whose grandparents live in a chloroquine resis-
shortly after this procedure, with normal blood flow
tant malaria belt in Africa. He wants to visit his grand-
through the LAD, the patient’s condition worsened. This
parents, and you want to give him primaquine as a
was most likely due to which of the following?
malaria prophylaxis, but before you do so, you should
test the patient for which of the following nonsymptom- (A) Disruption of the HMP shunt in cardiac cells
atic enzymatic deficiencies? (B) Damage to healthy cells by loss of essential enzymes
(A) Transketolase from cells due to membrane damage
(B) Pyruvate dehydrogenase (C) Development of intimal narrowing in another artery
(C) α-Ketoglutarate dehydrogenase (D) Radical-induced damage once blood flow was
reinitiated
(D) Glucose-6-phosphate dehydrogenase
(E) Lack of glycogen for ATP synthesis in the heart
(E) Glyceraldehyde-3-phosphate dehydrogenase

13 Consider an intestinal epithelial cell in S phase, and for

9 A patient has an insidious and steadily progressing neu-
which the major, active biosynthetic pathway is nucle-
rologic disorder that, after several years, results in wast-
otide synthesis. Which one of the following best repre-
ing and paralysis of the muscles of the limbs and trunk,
sents the activity state of a series of key enzymes under
loss of ability to speak, and swallowing difficulties. His
these conditions?
paternal uncle had the same disease. A mutation in
which enzyme may lead to these symptoms?
(A) Superoxide dismutase Glucose-
(B) Catalase 6-phosphate
dehydrogenase Transketolase PFK-1
(C) Myeloperoxidase
(D) NO synthase (A) Active Active Active
(E) Tyrosine hydroxylase
(B) Active Inactive Inactive
(C) Inactive Active Inactive
10 A researcher has generated a cell line in which the
γ-glutamyl cycle is defective, and glutathione cannot be (D) Inactive Inactive Active
synthesized. Which radical species might you initially (E) Inactive Active Active
expect to accumulate in this cell?

Chap14.indd 119 8/27/2009 1:10:21 PM

 120 Chapter 14

14 A researcher is studying cultured human hepatocytes Go phase of the cell cycle. Under such conditions,
and is examining the specific condition in which fatty what would be the activity state of the following
acid synthesis is activated, but the cell remains in the enzymes?

Glucose-6-phosphate Fructose-1,
dehydrogenase Transketolase Transaldolase 6-bisphosphatase

(A) Active Active Inactive Inactive

(B) Active Active Active Active
(C) Active Inactive Active Inactive
(D) Inactive Active Inactive Active
(E) Inactive Inactive Active Inactive

15 Individuals with a superactive glutathione reductase a healthier life style and replaced eggs and coffee for
will develop gout. This occurs due to which of the breakfast with fruit juices and whole-wheat toast. Within
following? 2 weeks of changing his diet, the man developed severe
(A) Activation of glucose-6-phosphate dehydrogenase muscle pain in his arms and shoulders. The muscle pain
(B) Inhibition of glucose-6-phosphate dehydrogenase could be the result of which of the following?
(C) Activation of transketolase (A) Induction of a detoxifying cytochrome P450 system
(D) Activation of transaldolase (B) Inhibition of a detoxifying cytochrome P450 system
(E) Inhibition of transketolase (C) Increased mevalonate inhibiting actin/myosin inter-
actions
16 Glucose-6-phosphate labeled in carbon 6 with 14C was (D) Increased mevalonate stabilizing actin/myosin inter-
added to a test tube with the enzymes phosphohexose actions
isomerase, PFK-1, aldolase, transketolase, and transal- (E) HMG-CoA stimulation of calcium efflux from the
dolase. ATP was also added to the test tube. At equilib- sarcoplasmic reticulum
rium, in which position would the radioactive label be
found in the newly produced ribose-5-phosphate? 19 A patient is recovering from acute respiratory distress
(A) 1 syndrome (ARDS). Which of the following is a major
(B) 2 antioxidant found in the fluid lining the bronchial
(C) 3 epithelium needed in high concentration for recovery
from ARDS?
(D) 4
(A) Glucuronic acid
(E) 5
(B) Pyruvate
17 Which one of the following disorders would lead to (C) Sorbitol
increased activity of the HMP shunt pathway? (D) Glycogen
(A) Glycogen phosphorylase deficiency (E) Glutathione
(B) Glucose-6-phosphatase deficiency
20 Which of the following biochemical pathways produces
(C) Fructose-1,6-bisphosphatase deficiency
the antioxidant referred to in the previous question?
(D) Pyruvate kinase deficiency
(A) TCA cycle
(E) Pyruvate dehydrogenase deficiency
(B) Glycolysis
18 A 45-year-old man was diagnosed with hypercholes- (C) γ-Glutamyl cycle
terolemia, for which he was prescribed a statin. After (D) HMP shunt
a month on medications, the patient decided to adopt (E) Polyol pathway

Chap14.indd 120 8/27/2009 1:10:21 PM

 HMP Shunt and Oxidative Reactions 121

ANSWERS glutathione to the compound for safe excretion, and

glutathione is a mercaptan (a compound with a free
1 The answer is B: A mercaptan. The man is suffer- sulfhydryl group). Individuals with acetaminophen
ing from acetaminophen poisoning. As shown below, poisoning are given N-acetyl cysteine as a mechanism
MEOS (the microsomal ethanol oxidizing system, also to increase glutathione production. Iron and vitamin
named CYP2E1) will convert acetaminophen into a C will not aid in detoxifying the toxic intermediate.
toxic intermediate. In a chronic alcoholic, the MEOS Rifampin blocks RNA polymerase in bacteria. Aspi-
has been induced and is very active. The toxic inter- rin will block cyclooxygenase, but will not stimulate
mediate (NAPQI) can be rendered inactive by adding NAPQI excretion.

O O O
H H H
N C CH3 N C CH3 N C CH3

Kidney, Kidney,
urine UDP-glucuronyl Sulfo transferase urine
transferase
Glucuronate OH SO4
Acetaminophen

EtOH CYP2E1
+

N-acetyl
O cysteine O O
H + H
N C CH3 N C CH3 N C CH3
GSH
Glutathione Cell proteins
SG S-transferase S-protein
OH O OH
Mercaptouric NAPQI
acid (N-acetyl-p-
benzoquinoneimine)
(toxic intermediate)
Kidney, urine

2 The answer is D: Induction of drug-metabolizing high levels of barbiturates being taken (due to the toler-
enzymes. Barbiturates are xenobiotics, and the body ance) are now toxic (the system that breaks down the
induces specific cytochrome P450 systems to help drug has been inhibited). Ethanol does not increase
detoxify and excrete the barbiturates. When the man absorption of the drug from the digestive tract, nor
first begins taking the drug, a low concentration of drug does acetaldehyde, ethanol’s oxidation product, react
is sufficient to exert a physiological effect, as the drug with barbiturates. Barbiturate action is not affected by
detoxifying system has not yet been induced. As the energy production (acetyl-CoA). The ethanol inhibition
detoxifying system is induced, however, higher concen- of cytochrome P450 systems is also not due to ethanol’s
trations of drug are required to have the same effect, dehydration effect.
as the rate of excretion of the drug is increased as the
detoxification system is induced. The “tolerance” to
drugs, in this case, is not due to downregulation of drug 4 The answer is C: Transketolase. The patient is experi-
receptors or decreased absorption of the drug from the encing the symptoms of vitamin B1 (thiamine) deficiency.
stomach. There is no induction of target gene expres- Ethanol blocks thiamine absorption from the gut, so in
sion, leading to enhanced drug action, nor are oppos- the United States, one will usually only see a B1 defi-
ing neurotransmitters expressed. The tolerance comes ciency in chronic alcoholics. One assay for B1 deficiency
about due to enhanced inactivation of the drug due to is to measure transketolase activity (which requires B1
the induction of drug-metabolizing enzymes. as an essential cofactor) in the presence and absence of
added B1. If the activity level increases when B1 is added,
3 The answer is B: Ethanol inhibition of a cytochrome P450 a vitamin deficiency is assumed. None of the other
system. Ethanol inhibits the drug detoxifying system enzymes listed (transaldolase, aldolase, β-ketothiolase,
for barbiturates; thus, in the presence of ethanol, the and acetylcholine synthase) require B1 as a cofactor,

Chap14.indd 121 8/27/2009 1:10:21 PM

 122 Chapter 14

and, thus, could not be used as a measure of B1 levels. occur. In addition, PFK-1 has been made nonfunctional,
A reaction catalyzed by transketolase is shown below such that glyceraldehyde-3-phosphate (G3P) cannot
(note the breakage of a carbon–carbon bond, and then be produced from either fructose-6-phosphate (F6P)
the synthesis of a carbon–carbon bond to generate the or glucose-6-phosphate (G6P). In order to generate
product of the reaction). ribose-5-phosphate (R5P) under these conditions,
both F6P and G3P need to be provided. These two
substrates will react, using transketolase as a substrate,
to generate erythrose-4-phosphate (E4P) and xylulose-
CH2OH 5-phosphate (X5P, step 1 in the figure below). The X5P
will be epimerized to ribulose-5-phosphate (Ru5P, step
C O
2 in the figure below), and then isomerized to R5P
HO C H (step 3 in the figure below). Glucose-6-phosphate can-
H C OH not be used as a substrate because it cannot be con-
CH2OPO3 2– verted to G3P (due to the block in PFK-1). Pyruvate
cannot be used as a substrate in extracts of red blood
Xylulose 5-phosphate
cells because such cells do not have pyruvate carboxy-
+ lase, so the pyruvate cannot be converted to either F6P
H O
or G3P.
C
H C OH
H C OH 3 Ribulose-5-P
2
epimerase epimerase
H C OH 3 isomerase

CH2OPO3 2– Xylulose-5-P Ribose-5-P Xylulose-5-P

Ribose 5-phosphate transketolase

Nonoxidative
Thiamine Glyceraldehyde-3-P Sedoheptulose-7-P 1 reactions
pyrophosphate Transketolase
transaldolase
Erythrose-4-P transketolase
H O
C Fructose-6-P Fructose-6-P Glyceraldehyde-3-P

H C OH
CH2OPO3 2–
Glyceraldehyde 3-phosphate 6 The answer is D: Xylulose-5-phosphate. In order for
+ ribose-5-phosphate to be converted to glucose-6-phos-
phate, the nonoxidative reactions of the HMP shunt
CH2OH pathway must be used (the oxidative steps are not revers-
C O ible reactions). In order for this to occur, the ribose-5-
HO C H
phosphate is isomerized to ribulose-5-phosphate, which
is then epimerized to xylulose-5-phosphate (steps 1 and
H C OH
2 in the figure on page 123). R5P and X5P then initi-
H C OH ate a series of reactions utilizing transketolase (step 3 in
H C OH the figure on page 123) and transaldolase (step 4 in the
figure on page 123) to generate fructose-6-phosphate,
CH2OPO3 2–
which can be isomerized to glucose-6-phosphate (step 5
Sedoheptulose 7-phosphate in the figure on page 123). Glyceraldehyde-3-phosphate
is also formed during this series of reactions, which
then goes back to fructose-6-phosphate production.
Pyruvate, oxaloacetate, 1,3-bisphosphoglycerate, and
5 The answer is C: Fructose-6-phosphate and glycer-
6-phosphogluconoate are not obligatory intermediates
aldehyde-3-phosphate. In the absence of NADP+,
in this conversion.
the oxidative steps of the HMP shunt pathway are
nonfunctional, so only the nonoxidative steps will

Chap14.indd 122 8/27/2009 1:10:22 PM

 HMP Shunt and Oxidative Reactions 123
3 Ribulose-5-P
2 2
epimerase isomerase epimerase
1

Xylulose-5-P Ribose-5-P Xylulose-5-P

transketolase 3 Nonoxidative
reactions

Glyceraldehyde-3-P Sedoheptulose-7-P

transaldolase 4
Erythrose-4-P transketolase

Fructose-6-P Fructose-6-P Glyceraldehyde-3-P

phosphohexoseisomerase
5 Dihydroxyacetone phosphate
Glucose-6-P
Fructose 1,6-bisphosphate
Answer 6

7 The answer is B: Oxidative damage to red blood cell membranes from oxidative damage. In the presence
membranes. The man has glucose-6-phosphate of a strong oxidizing agent (the new drug the patient
dehydrogenase deficiency and is incapable of regen- was taking), the red cell membranes undergo oxidative
erating reduced glutathione to protect red blood cell damage and the red cell bursts, leading to hemolytic
anemia. This is all due to a lack of protective glutathi-
one in the membrane. As the red cell lacks a nucleus,
A – the cell cannot induce new gene synthesis. The drug the
COO
patient was taking does not induce ion pores in red cell
CH2 Glycine
membranes or inhibit the HMP shunt pathway. It also
HN
does not cause oxidative damage to bone marrow. The
C O drugs to avoid while prescribing for a patient with a
HS CH2 CH Cysteine G6PDH deficiency include primaquine, dapsone, nitro-
GSH HN furantoin, and sulfonylurea. The reduced (Panel A) and
C O
oxidized (Panel B) forms of glutathione are indicated to
the side.
CH2
Glutamate
CH2
HCNH3+ 8 The answer is D: Glucose-6-phosphate dehydrogenase.
COO– Given the demographics of the patient’s ancestry (and
the need for obtaining an accurate history), and the
B – –
fact that the patient is a male, the patient may have
COO COO
glucose-6-phosphate dehydrogenase deficiency (an
CH2 CH2 Glycine X-linked disorder). If a person with this enzyme defi-
HN HN ciency is given primaquine, which is a strong oxidiz-
C O C O ing agent, hemolytic anemia is likely to develop. If a
HC CH2 CH2 CH Cysteine physician suspects that a patient may have such an
S S
GSSG
enzymatic deficiency, it is imperative to check before
HN HN
prescribing strong oxidizing agents to the patient,
C O C O or prescribe another antimalarial prophylaxis that is
CH2 CH2 not a strong oxidizing agent (such as tetracycline). If
CH2 Glutamate individuals were deficient in transketolase, pyruvate
CH2
HCNH3+ HCNH3+
dehydrogenase, α-ketoglutarate dehydrogenase, or
– glyceraldehyde-3-phosphate dehydrogenase, red cell
COO COO–
lysis would not occur. One should also recall that
the red cells lack mitochondria, so these cells do not
Answer 7: Panel A indicates reduced glutathione (GSH) while Panel contain pyruvate dehydrogenase or α-ketoglutarate
B indicates oxidized glutathione (GSSG). dehydrogenase.

Chap14.indd 123 8/27/2009 1:10:23 PM

 124 Chapter 14

in individuals with glucose-6-phosphate dehydrogenase

9 The answer is A: Superoxide dismutase. The patient
deficiency; in individuals with a normal G6PDH, the
is experiencing the symptoms of familial ALS. A muta-
oxidizing agent is handled by glutathione. The red blood
tion in superoxide dismutase 1 (SOD1) in humans has
cells, under these conditions, do not have a problem in
been linked to the development of familial ALS through
regenerating NADH, NAD+, or ATP.
an unknown mechanism. Familial ALS only constitutes
between 5% and 10% of all ALS cases diagnosed. The
disease process, when SOD1 is mutated, is not linked to 12 The answer is D: Radical induced damage once blood flow
a loss of enzymatic activity, although the SOD1 may have was reinitiated. The patient is experiencing ischemic
been mutated such that it will produce other radical spe- reperfusion injury. When oxygen delivery to cardiac
cies and is no longer specific for superoxide. A second cells was compromised, the electron transfer chain in
model proposes a misfolding problem similar to prion the mitochondria was fully reduced, as the terminal
disease. For more information on such models see oxygen acceptor was missing. When oxygen is reintro-
Nature Med. 2000;6:1320–1321 and Ann Neurol. 2007 duced to the cell, at a high concentration, the likelihood
Dec;62(6):553–559. None of the other enzymes listed of electron transfer from reduced coenzyme Q to oxy-
(catalase, myeloperoxidase, NO synthase, and tyrosine gen is increased, such that the possibility of superoxide
hydroxylase) have been linked to the development of ALS, generation is increased. The superoxide produced reacts
or an ALSlike disease. The reaction catalyzed by SOD1 is with lipids and proteins and can lead to cell death above
shown below. that originally occurring from the initial heart attack.
Radicals do not form during the ischemic event since
2 O2– oxygen is missing from the tissues. There is no effect
on glycogen stores or the HMP shunt pathway under
Superoxide
these conditions. Intimal narrowing occurs over a long
2H+
Superoxide
time period, not over the short time period covered in
dismutase this case. Injured cells do leak enzymes into the blood-
O2 stream, but these enzymes do not cause the death of
other, healthy cells.
H2O2

Hydrogen peroxide 13 The answer is E. Under the conditions described,

DNA synthesis is occurring without any requirement
10 The answer is D: Hydrogen peroxide. In the absence for NADPH (such as fatty acid synthesis). Under these
of glutathione, the enzyme glutathione peroxidase conditions, NADPH levels are high and glucose-6-
will be less active due to the lowered concentration phosphate dehydrogenase is inactive. The cell requires
of glutathione. Glutathione peroxidase catalyzes the ribose-5-phosphate, however, for nucleotide biosynthe-
oxidation of two reduced glutathione molecules by sis, and this is synthesized from fructose-6-phosphate
hydrogen peroxide, generating oxidized glutathione and glyceraldehyde-3-phosphate using the nonoxida-
and two molecules of water. As glutathione peroxidase tive reactions of the pathway. Thus, both transketolase
is one mechanism whereby hydrogen peroxide levels and transaldolase will be active under these conditions.
are reduced, hydrogen peroxide would be expected to PFK-1 is active as well, as the only way to generate glyc-
accumulate, and can then lead to radical damage of eraldehyde-3-phosphate from a sugar precursor is via
membrane proteins and lipids. Glutathione peroxidase enzymes of the glycolytic pathway.
does not require, or react with, superoxide, nitrogen
dioxide, nitrous oxide, and peroxynitrate. It is possible 14 The answer is B. The conditions of the cell indicate
that under these conditions, superoxide would also that NADPH is required for fatty acid synthesis, but
accumulate, due to the increase in concentration of there is no need for ribose-5-phosphate, as the cells
one of the reaction products of superoxide dismutase, are in Go phase and are not undergoing DNA synthesis
hydrogen peroxide. However, there is no evidence that (so nucleotides are not required). The HMP shunt will
hydrogen peroxide accumulation will inhibit the reac- utilize the oxidative reactions to generate NADPH,
tion catalyzed by superoxide dismutase. and then the ribulose-5-phosphate produced will use
the nonoxidative reactions to regenerate glucose-6
11 The answer is C: Reduced glutathione. The patient has -phosphate. For this to occur, transketolase, transal-
glucose-6-phosphate dehydrogenase deficiency, and dolase, glucose-6-phosphate dehydrogenase (as the
his red blood cells cannot convert oxidized glutathi- major oxidative enzyme of the pathway), and fruc-
one to reduced glutathione due to a lack of NADPH. tose-1,6-bisphosphatase all have to be active. These
Fava beans contain a potent oxidizing agent that will, nonoxidative reactions are indicated in the figure on
in some patients (but not all), lead to hemolytic anemia page 125.

Chap14.indd 124 8/27/2009 1:10:25 PM

 HMP Shunt and Oxidative Reactions 125
3 Ribulose-5-P
2 2
epimerase isomerase epimerase
1

Xylulose-5-P Ribose-5-P Xylulose-5-P

transketolase 3 Nonoxidative
reactions

Glyceraldehyde-3-P Sedoheptulose-7-P

transaldolase 4
Erythrose-4-P transketolase

Fructose-6-P Fructose-6-P Glyceraldehyde-3-P

phosphohexoseisomerase
5 fructose 1,6- Dihydroxyacetone phosphate
Glucose-6-P bisphosphatase

Fructose 1,6-bisphosphate
Answer 14
15 The answer is A: Activation of glucose-6-phosphate take place. In order for the nonoxidative reactions to
dehydrogenase. Glutathione reductase will utilize occur, the glucose-6-phosphate (G6P, labeled in the 6th
NADPH and reduce oxidized glutathione to reduced glu- position with 14C) must pass through glycolysis to pro-
tathione, generating NADP+. If Glutathione reductase is duce fructose-6-phosphate (F6P, labeled in the 6th posi-
superactive, NADP+ levels accumulate, which activates tion) and glyceraldehyde-3-phosphate (labeled in the
glucose-6-phosphate dehydrogenase. This will lead to 3rd position). Transketolase will allow these two com-
NADPH production via the oxidative reactions of the pounds to exchange carbons, which would generate
HMP shunt, along with ribulose-5-phosphate (Ru5P). erythrose-4-phosphate (E4P, labeled in the 4th position)
The Ru5P will lead to increased ribose-5-phosphate pro- and xylulose-5-phosphate (X5P, labeled in the 5th posi-
duction, increased 5′-phosphoribosyl 1′-pyrophosphate tion). The X5P can then go to ribulose-5-phosphate
(PRPP) production, and increased 5′-phosphoribosyl (Ru5P) and ribose-5-phosphate (R5P), labeled in the
1′-amine levels. This eventually leads to increased fifth positions. The E4P (labeled in the 4th position) can
purine production, in excess of what is required. The react with another molecule of F6P (labeled in the 6th
excess purines are converted to uric acid, and excess position) using transaldolase to generate sedoheptulose
uric acid will lead to gout. A superactive glutathione 7-phosphate (Se7P, labeled in the 7th position) and
reductase will not lead to an alteration in the activities glyceraldehyde-3-phosphate (G3P), labeled in the 3rd
of transketolase or transaldolase. position. Transketolase will then convert the Se7P and
G3P to R5P and X5P, both labeled in the 5th positions.
16 The answer is E: 5. Given the enzymes present, only The nonoxidative reactions can be seen, schematically,
the nonoxidative reactions of the HMP shunt would in the figure below.

3 Ribulose-5-P
2 2
epimerase isomerase epimerase
1

Xylulose-5-P Ribose-5-P Xylulose-5-P

transketolase 3 Nonoxidative
reactions

Glyceraldehyde-3-P Sedoheptulose-7-P

transaldolase 4
Erythrose-4-P transketolase

Fructose-6-P Fructose-6-P Glyceraldehyde-3-P

phosphohexoseisomerase
5 Dihydroxyacetone phosphate
Glucose-6-P
Fructose 1,6-bisphosphate

Chap14.indd 125 8/27/2009 1:10:26 PM

 126 Chapter 14

levels are increasing cannot be correct; they are reduced

17 The answer is B: Glucose-6-phosphatase deficiency.
in the presence of a statin. Statins do not bring about
The HMP shunt can have increased activity under two
calcium efflux from the sarcoplasmic reticulum.
conditions, one being an increase in the cofactor NADP+
levels and the other being an increase in the substrate
levels (glucose-6-phosphate). The only enzyme listed, 19 The answer is E: Glutathione. Glutathione is the major
which when defective would lead to an increase in either antioxidant in the fluid lining the bronchial epithelium.
glucose-6-phosphate or NADPH, is glucose-6-phos- It is essential for recovery of these tissues. Depletion of
phatase. A deficiency in glycogen phosphorylase would glutathione in the airway is thought to greatly increase
not produce glucose-1-phosphate; thus, there would not a person’s susceptibility to upper respiratory infec-
be an increase in the HMP shunt under these conditions. tions such as influenza. Glutathione is formed in the
A deficiency in fructose-1,6-bisphosphatase deficiency γ-glutamyl pathway, and oxidized glutathione is regen-
would impair gluconeogenesis and would not lead to the erated to reduced glutathione using NADPH produced
synthesis of glucose-6-phosphate. Deficiencies in either by the HMP shunt pathway. None of the other answers
pyruvate carboxylase or pyruvate dehydrogenase would (glycogen, sorbitol, pyruvate, and glucuronate) offer
lead to pyruvate accumulation and NAD+ accumulation, protection against oxidative damage. Glycogen is utilized
but not NADP+ or glucose-6-phosphate accumulation. for the storage of glucose. Pyruvate is the end product of
glycolysis. Sorbitol is a product of the polyol pathway.
18 The answer is B: Inhibition of a detoxifying cytochrome Glucuronic acid is used for xenobiotic metabolism, in
P450 system. The patient is suffering from the potential general, to increase the solubility of the xenobiotic and
side effects of statins, namely, muscle damage and to prepare it for excretion.
pain. This may occur due to an inhibition of coenzyme
Q synthesis (which requires a product derived from 20 The answer is C: g-Glutamyl cycle. Glutathione is pro-
mevalonic acid) and a lack of energy generation in the duced via the γ-glutamyl cycle; the HMP shunt pathway
muscle. The reason this comes about is that statins are provides the NADPH that allows oxidized glutathione
detoxified through a cytochrome P450 system, and the to be converted to reduced glutathione. The other path-
particular system that works on statins is inhibited by ways listed (TCA cycle, glycolysis, HMP shunt, and the
grapefruit juice. Thus, in the presence of grapefruit juice, polyol pathway) do not provide for glutathione synthe-
the effective intracellular levels of statins are higher than sis. The TCA cycle is designed to oxidize acetyl-CoA to
in the absence of the juice, due to the decreased rate of carbon dioxide and water. Glycolysis is the entry point of
destruction. The artificially induced higher levels of statins sugars into metabolism. The HMP shunt pathway gen-
then lead to muscle damage. Statins inhibit the conversion erates five-carbon sugars and NADPH, and the polyol
of HMG-CoA to mevalonic acid (catalyzed by HMG-CoA pathway generates sugar alcohols. The γ-glutamyl cycle
reductase). Thus, answers indicating that mevalonic acid is shown in the figure below.

ADP + Pi ATP

Amino
acid
Glutathione
γ-Glutamylcysteine
γ-Glutamyl Glycine
transpeptidase
ADP + Pi
Cysteinylglycine
Answer 20: In cells of the intestine and kidney, amino
acids can be transported across the cell membrane by
Cysteine ATP reacting with glutathione to form a γ-glutamyl amino
acid. The amino acid is released into the cell and glu-
γ-Glutamyl amino acid
5-Oxoprolinase
tathione is resynthesized. However, the major role of
this cycle is glutathione synthesis because many tissues
5-Oxoproline Glutamate
lack the transpeptidase and 5-oxoprolinase activities.
Thus, the reactions performed by most cells include
the condensation of cysteine and glutamate to form
Amino ATP ADP + Pi γ-glutamylcysteine and then the condensation of
acid γ-glutamylcysteine with glycine to form glutathione.

Chap14.indd 126 8/27/2009 1:10:28 PM

 Chapter 15

Amino Acid
Metabolism
and the Urea Cycle
This chapter quizzes the student on amino acid most often results from a defect in which of the following
metabolism and products derived from amino acids. enzymes?
(A) Phenylalanine hydroxylase
QUESTIONS (B) NADPH oxidase
Select the single best answer. (C) Dihydrofolate reductase
(D) Tyrosinase
1 Routine newborn screening identified a child with (E) Homogentisic acid oxidase
elevated levels of phenylpyruvate and phenyllactate in
the blood. Despite treating the child with a restricted 3 A newborn becomes lethargic and drowsy 24 h after
diet, evidence of developmental delay became apparent. birth. Blood analysis shows hyperammonemia, coupled
Supplementation with which of the following would be with orotic aciduria. This individual has an enzyme
beneficial to the child? deficiency that leads to an inability to directly produce
(A) Tyrosine which of the following?
(B) 5-hydroxytryptophan (A) Carbamoyl phosphate
(C) Melanin (B) Ornithine
(D) Phenylalanine (C) Citrulline
(E) Alanine (D) Argininosuccinate
(E) Arginine
2 A newborn has milky white skin, white hair, and red-
appearing eye color (see the figure below). This disorder
4 Considering the patient in question 3, orotic acid levels
are high in this patient due to which of the following?
(A) Elevated ammonia
(B) Elevated glutamine
(C) Bypassing carbamoyl phosphate synthetase II
(CPS-II)
(D) Bypassing aspartate transcarbamoylase
(E) Inhibition of carbamoyl phosphate synthetase I
(CPS-I)

5 Considering the patient discussed in the last two ques-

tions, a potential treatment for the patient is supple-
mentation with which of the following?
(A) Arginine and glutamine
(B) Lysine and glutamine
(C) Arginine and benzoate
(D) Lysine and benzoate
(E) Glutamine and phenylbutyrate

127

Chap15.indd 127 8/26/2009 4:30:16 PM

 128 Chapter 15

6 Parents bring their 6-year-old son to the pediatrician (reminiscent of Marfan syndrome patients), scoliosis,
due to the parents being concerned about “mental retar- pectus excavatum, displaced lens, and muscular hypo-
dation.” Blood work demonstrated a microcytic anemia tonia. Blood work is likely to show an elevation of which
and basophilic stippling. During the patient history, of the following metabolites?
it became apparent that the boy often stayed with his (A) Methionine
grandparents, who owned a 150-year-old apartment. (B) Phenylpyruvate
The boy admitted to eating paint chips from the radia- (C) Cysteine
tors in the apartment. The boy’s anemia is most likely (D) Fibrillin fragments
the result of which one of the following? (E) Homocystine
(A) Inhibition of iron transport
(B) Reduction of heme synthesis 11 Considering the patient described in the previous ques-
(C) Inhibition of the phosphatidyl inositol cycle tions, treatment with which of the following vitamins
(D) Blockage of reticulocyte DNA synthesis may be successful in controlling this disorder?
(E) Inhibition of β-globin gene expression (A) B1
(B) B2
7 Routine newborn screening identified a child with ele- (C) B3
vated levels of α-ketoacids of the branched-chain amino (D) B6
acids. A certain subset of such children will respond well (E) B12
to which of the following vitamin supplementation?
(A) Niacin 12 A 13-year-old boy is admitted to the hospital due to
(B) Riboflavin flank and urinary pain. Analysis demonstrates the pres-
(C) B12 ence of kidney stones. The stones were composed of
(D) B6 calcium oxalate. Family history revealed that the boy’s
(E) Thiamine father and mother had had similar problems. Oxalate
accumulation arises in this patient due to difficulty in
8 Another routine newborn screening identified a child metabolizing which of the following?
with elevated levels of the branched-chain amino acids (A) Alanine
and their α-ketoacid derivatives. In addition, the child (B) Leucine
also exhibited lactic acidosis. Which enzyme listed below (C) Lysine
would you expect to be negatively affected (reduced (D) Glyoxylate
activity) by this disorder? (E) Glycine
(A) α-ketoglutarate dehydrogenase
(B) Isocitrate dehydrogenase 13 An 18-year-old boy was brought to the hospital by his
(C) Malate dehydrogenase mother due to a sudden onset of flank pain in his left
(D) Succinate dehydrogenase side, radiating toward his pubic area. His urine was
(E) Acetyl-CoA carboxylase reddish-brown in color, and a urinalysis showed the
presence of many red blood cells. When his urine was
9 A Russian child, 5 years old, was brought to the pedia- acidified with acetic acid, clusters of flat, hexagonal
trician for developmental delay. Blood analysis showed transparent crystals were noted. A radiograph of the
elevated levels of phenylalanine, phenyllactate, and abdomen showed radio-opaque stones in both kidneys.
phenylpyruvate. The developmental delay, in this con- The boy eventually passed a stone whose major com-
dition, has been hypothesized to occur due to which of ponent was identified as cystine. A suggestion for treat-
the following? ment is which of the following?
(A) Acidosis due to elevated phenyllactate (A) Increased ethanol consumption
(B) Lack of tyrosine, now an essential amino acid (B) Restriction of dietary methionine
(C) Inhibition of hydroxylating enzymes due to accu- (C) Utilize drugs that acidify the urine
mulation of phenylalanine (D) Restrict dietary glycine
(D) Lack of large, neutral amino acids in the brain (E) Prescribe diuretics
(E) Inhibition of neuronal glycolysis by phenylpyruvate
14 You have an elderly patient with a history of heart
10 A 12-year-old boy is brought to the pediatrician because attacks (MIs) and strokes (CVAs). Blood work indi-
of behavioral problems noted by the parents. Upon cates an elevated homocysteine level, which is reduced
examination, the physician notices brittle and coarse by the patient taking pharmacological doses of pyri-
hair, red patches on the skin, long, thin arms and legs doxamine. An enzyme that would benefit from such

Chap15.indd 128 8/26/2009 4:30:17 PM

 Amino Acid Metabolism and the Urea Cycle 129
treatment in lowering homocysteine levels is which of 18 A patient presents with episodes of flushing, diarrhea,
the following? abdominal cramping, and wheezing. His blood pres-
(A) Methionine synthase sure and pulse rate are normal during these episodes.
(B) N5, N10 methylene tetrahydrofolate reductase Physical exam is normal except for scattered telangi-
(C) Cystathionine β-synthase ectasias. In order to diagnose this problem, a 24-h urine
(D) Cystathionase collection for which of the following would be most
(E) S-adenosyl homocysteine hydrolase appropriate?
(A) Vanillylmandelic acid (VMAs)
15 A 3-month-old boy of French–Canadian ancestry is seen (B) Catechols
by the pediatrician for failure to thrive and poor appe- (C) Dopamine
tite. Physical exam denotes hepatomegaly and a yellow- (D) 5-hydroxyindoleacetic acid (5-HIAA)
ing of the eyes. The boy had been vomiting and had (E) Cortisol
diarrhea, and a distinct cabbagelike odor was apparent.
This disorder is due to a defect in the metabolism of
which of the following amino acids? 19 A patient taking a drug for depression experienced a
(A) Alanine greatly increased heart rate and sweating after eating
red wine and gourmet, aged cheese. These symptoms
(B) Tryptophan
appeared due to an inability to degrade which of the
(C) Tyrosine
following?
(D) Histidine
(A) Tyrosine
(E) Lysine
(B) Tyramine
(C) Serotonin
16 Mr Smith had been prescribed a drug to treat his
depression. One of the effects of the drug is to maintain (D) Glycine
elevated levels of a particular neurotransmitter that has (E) Glutamate
been derived from which of the following amino acids?
(A) Tryptophan 20 A 6-year-old boy is slightly anemic and is very sensi-
(B) Tyrosine tive to the sun, to the point where his skin blisters
(C) Glutamate instead of healing normally from sunburn. His con-
(D) Histidine dition worsened when he was taking rifampin for a
(E) Glycine Methicillin Resistant Staph Aureus. The boy most
likely has a defect in which of the following biochemi-
17 A patient has a “pill rolling” tremor, “cogwheel” rigid- cal pathways?
ity, bradykinesis, speech difficulties, and a shuffling (A) Glycogen synthesis
gait. The chemical that is lacking in this syndrome is a (B) Fatty acid oxidation
derivative of which of the following amino acids? (C) DNA repair
(A) Alanine (D) Transcription-coupled DNA repair
(B) Serine (E) Heme synthesis
(C) Tyrosine
(D) Tryptophan
(E) Phenylalanine

Chap15.indd 129 8/26/2009 4:30:17 PM

 130 Chapter 15

ANSWERS and norepinephrine) and serotonin cannot be synthesized

as those pathways require tetrahydrobiopterin. Giving
1 The answer is B: 5-hydroxytryptophan. The child has 5-hydroxytryptophan bypasses the block in serotonin bio-
nonclassical phenylketonuria (PKU). Classical PKU is due synthesis, and would have to be a supplement for these
to a defect in phenylalanine hydroxylase, leading to accu- children along with dihydroxyphenylalanine (DOPA),
mulation of phenylalanine derivatives. These interfere with which is the hydroxylated precursor for catecholamine
amino acid transport into the brain and can lead to cogni- biosynthesis. Providing tyrosine will not overcome the
tive disorders if not treated, usually, by a low-phenylalanine block in neurotransmitter biosynthesis. Providing pheny-
diet. However, in nonclassical PKU, the required cofactor lalanine just makes the problem worse. Neither melanin
for the phenylalanine hydroxylase reaction, tetrahydro- nor alanine will bypass the metabolic block of this disease.
biopterin, is deficient. This will lead to similar biochemical The role of tetrahydrobiopterin, indicating its oxidation
symptoms (elevation of phenylalanine derivatives), but, in and subsequent reduction, in the phenylalanine hydroxy-
addition, the catecholamines (dopamine, epinephrine, lase reaction is shown below.

GTP

Biosynthesis

+
NH3
H
N N H CH2 CH COO–
H2N H
NAD+ Phenylalanine
HN H
N CH CH CH3
O H O2
OH OH
Tetrahydrobiopterin
Dihydropteridine Phenylalanine
(BH4)
reductase hydroxylase

H H2O
N N H
H2N H
NADH + H+ +
H NH3
N
N CH CH CH3 HO CH2 CH COO–
O OH OH
Tyrosine
Quinonoid dihydrobiopterin
(BH2)

2 The answer is D: Tyrosinase. The child has albinism, a 3 The answer is C: Citrulline. The child has ornithine tran-
lack of pigment in the skin cells, which is produced by scarbamoylase (OTC) deficiency, and cannot condense
melanocytes. Melanocyte tyrosinase (a different isozyme carbamoyl phosphate with ornithine to produce citrul-
than the neuronal tyrosinase that produces DOPA for line (see the figure on page 131). The excess carbamoyl
catecholamine biosynthesis) is defective in albinism. The phosphate produced leaks into the cytoplasm where it
DOPA produced is then used for pigment production. bypasses the regulated enzyme of de novo pyrimidine
A lack of phenylalanine hydroxylase leads to PKU. A lack production, leading to excess orotic acid. Thus, in an
of dihydrofolate reductase is most likely a lethal event as OTC defect, carbamoyl phosphate can be produced, but
there are no reported cases of a lack of this enzyme. Tetra- citrulline cannot. Since citrulline cannot be produced,
hydrofolate is not required for the conversion of tyrosine the later products of the urea cycle (argininosuccinate
to DOPA in melanocytes. NADPH oxidase generates and arginine) are also produced at lower levels than nor-
superoxide, which is not part of this pathway. Homogen- mal, which is an indirect effect due to the inability to
tisic acid is part of the phenylalanine and tyrosine degra- produce citrulline.
dation pathways, and is not involved in albinism.

Chap15.indd 130 8/26/2009 4:30:18 PM

 Amino Acid Metabolism and the Urea Cycle 131

Mitochondrion
CO2 + H2O Cytosol
Urine

– + NH2
HCO3 + NH4
Urea C O NH2
NH2 H2O C NH
2 ATP Carbamoyl 5 CH2 NH
phosphate
synthetase I Arginase CH2
(CPSI)
CH2NH2 CH2
2 ADP 1
+ Pi CH2 H C NH2
CH2NH2
CH2
CH2 COOH
COOH
O O H C NH2 Arginine
CH2
HC
H2N C O P O– COOH
H C NH2
Ornithine 4 CH
O– COOH
Carbamoyl Ornithine Argininosuccinate COOH
2 Ornithine lyase
phosphate transcarbamoylase Fumarate

NH2
NH2 NH COOH
Pi C O
C O C NH CH
CH2 NH
CH2 NH CH2 NH CH2
CH2 COOH
CH2 CH2
CH2
CH2 CH2
H C NH2 3
H C NH2 H C NH2
COOH Argininosuccinate
COOH synthetase COOH
Citrulline
Citrulline Argininosuccinate
ATP AMP + PPi
COOH
H2N C H
CH2
COOH
Aspartate

Answer 3: The urea cycle. Reaction 2 is defective in the disease described in this case.

4 The answer is C: Bypassing carbamoyl phosphate syn- CPS-II, and while glutamine is also elevated, and is a
thetase II (CPS-II). The rate-limiting step for de novo substrate of CPS-II, higher glutamine concentrations
pyrimidine synthesis is carbamoyl phosphate synthetase will not overcome enzyme inhibition by its allosteric
II (CPS-II), which produces carbamoyl phosphate in the inhibitor, UTP. Aspartate transcarbamoylase is the regu-
cytoplasm (see the figure on page 132). In an OTC defi- lated step of pyrimidine biosynthesis in many prokary-
ciency, the carbamoyl phosphate produced in the mito- otic cells, but not in humans. This step is necessary for
chondria leaks into the cytoplasm, leading to orotic acid pyrimidines to be synthesized starting with carbam-
synthesis as the regulated step of the pathway is being oyl phosphate. CPS-I is a mitochondrial enzyme not
bypassed. The elevated ammonia is not a substrate of involved in pyrimidine production.

Chap15.indd 131 8/26/2009 4:30:18 PM

 132 Chapter 15

Glutamine + CO2 + 2ATP −SCoA

A
CPS-II
UTP – + PRPP ATP AMP + PPi
C (activation) C O
Carbamoyl phosphate
O O− SCoA
Aspartate

O H
−O C C H (Glycine)
NH+3
Orotate
PRPP −SCoA
C O C O
Hippuric acid
SCoA NH (excreted)
CO2
CH2
UMP
C
RR O O−
UDP dUDP

UTP B O O
CH2CH2CH2 C CH2 C
RNA
Glutamine PI O− O−

CTP NH4+ β-Oxidation

dUMP
5,10-Methylene-FH4 Phenylbutyrate Phenylacetate
CDP dCMP O CoAS−
RR FH2 CH2 C ATP
dCTP dCDP dTMP SCoA
O AMP + PPi
DNA
C NH2
dTTP dTDP CH2
An overview of pyrimidine synthesis, indicating the regulation that CH2
occurs at the carbamoyl phosphate synthetase II step. If carbamoyl H C NH3+ HSCoA
phosphate can be generated outside of this pathway (as in an orni-
thine transcarbamoylase deficiency), then pyrimidine synthesis will C
bypass its regulated step, and an overproduction of pyrimidines O O−
O O
would result. (Glutamine) H
CH2 C NH C CH2CH2 C NH2
C
O O−
5 The answer is C: Arginine and benzoate. Whenever Phenylacetylglutamine
there is a urea cycle defect, arginine becomes an essential (excreted)
amino acid (as its route of synthesis is the urea cycle).
Benzoate, along with phenylbutyrate, is given to patients Removal of nitrogen using benzoic acid (panel A) and phenyl-
with urea cycle defects to conjugate with a nitrogen car- butyrate (panel B).
rying molecule (benzoate conjugates with glycine while
phenylbutyrate, after activation to phenylacetate, con-
jugates with glutamine), which is then excreted. The 6 The answer is B: Reduction of heme synthesis. The
reactions of benzoate and phenylbutyrate with nitrogen boy is suffering from lead poisoning, which he obtained
containing amino acids are shown above. The excretion from eating the flaking paint chips. Lead inhibits the
of glycyl-benzoate reduces the glycine levels of the body, δ-aminolevulinic acid dehydratase step of heme synthe-
forcing more glycine to be produced and providing sis, leading to reduced heme levels (see the figure on page
an alternative pathway for nitrogen disposal in the 133). In addition, the ferrochelatase step (in which iron
absence of a functional urea cycle. Giving lysine or glu- is inserted into the newly synthesized heme ring) is also
tamine will not help to reduce ammonia levels in the inhibited by lead. The reduced heme levels reduce the
patient. amount of functional hemoglobin synthesized, leading

Chap15.indd 132 8/26/2009 4:30:19 PM

 Amino Acid Metabolism and the Urea Cycle 133
to the microcytic anemia observed in the child. Lead which requires the same five cofactors as do pyruvate
does not interfere with iron transport or inhibit part of and α-ketoglutarate dehydrogenase; thiamine, NAD+,
the phosphatidyl inositol cycle (lithium is the metal that FAD, lipoic acid, and coenzyme A. A subset of patients
does that). DNA synthesis is not impaired by lead, nor with this disorder has a mutation in the E1 subunit of the
does lead inhibit gene expression of the globin chains. enzyme, which has reduced the affinity of the enzyme
Cytochrome synthesis is also decreased and may con- for vitamin B1. Increasing the concentration of B1 can
tribute to the lethargy observed in the child. therefore overcome the effects of the mutation and allow
the enzyme to exhibit sufficient activity to reduce the
COO–
buildup of the toxic metabolites. While niacin and ribo-
– flavin are required for the enzyme, the mutation in the
COO CH2
enzyme is such that the affinity of these cofactors for the
CH2 CH2 enzyme has not been altered. B12 and B6 are not required
CH2 O C for this reaction.
C O H C H
CH2 H 8 The answer is A: a-ketoglutarate dehydrogenase. The
NH2 NH child has a mutation in the shared E3 subunit of pyru-
2 δ-ALA vate dehydrogenase, α-ketoglutarate dehydrogenase,
and the branched-chain α-ketoacid dehydrogenase. All
δ-ALA three reactions are oxidative decarboxylation reactions
dehydratase
2H2O
and utilize a three-component enzyme complex, des-
ignated as E1, E2, and E3 (see the figure below). The
E1 subunit binds thiamine pyrophosphate and cata-
COO–
lyzes the decarboxylation reaction. The E2 subunit is a
COO– CH2
transacylase and is involved in the oxidation–reduction
CH2 CH2 part of the reaction. The E3 component (dihydrolipoyl
C C dehydrogenase) is shared among all three enzymes,
C CH and a mutation in this subunit will affect the activity
of all three enzymes. This subunit reduces NAD+, using
CH2 N
H electrons obtained from reduced lipoic acid. The key
NH2
to solving the problem is the recognition that lactic
Porphobilinogen acidosis occurs, which would happen when pyruvate
(a pyrrole)
dehydrogenase was defective. None of the other dehy-
One of the two steps in heme biosynthesis that is sensitive to lead. drogenases listed (isocitrate dehydrogenase, malate
dehydrogenase, and succinate dehydrogenase) require
7 The answer is E: Thiamine. The child has maple syrup the E3 subunit for their activity, nor do they catalyze
urine disease, a defect in the branched-chain α-keto oxidative decarboxylation reactions. Acetyl-CoA car-
acid dehydrogenase step that utilizes all three branched- boxylase catalyzes a carboxylation reaction, and does
chain α-keto acids as substrates. The reaction catalyzed not share subunits with the enzymes that catalyze oxi-
by this enzyme is an oxidative decarboxylation reaction, dative decarboxylations.

OH
R C TPP FAD (2H) NAD+
S Dihydrolipoyl DH
H S Lip E3 5
Answer 8: Mechanism of α-keto acid dehy- α-Keto FAD
CO2 trans Ac 4 NADH
drogenase complexes. R represents the portion acid DH
+ H+
of the α-keto acid that begins with the β car- SH
1 E1 2 E2 trans Ac
bon. Three different subunits are required for R Lip SH
the reaction: E1 (α-ketoacid decarboxylase), O
C O trans Ac 3
E2 (transacylase), and E3 (dihydrolipoyl dehy- α-Keto
R C SCoA
drogenase). TPP refers to the cofactor thiamine COO– acid DH
Lip O
pyrophosphate. Lip refers to the cofactor lipoic CoASH
α-Keto acid TPP HS S C R
acid.

Chap15.indd 133 8/26/2009 4:30:21 PM

 134 Chapter 15

9 The answer is D: Lack of large, neutral amino acids in is a diagnostic marker for PKU, but it is not relevant
the brain. The child has PKU. The elevated pheny- for homocysteine production or degradation. Fibrillin
lalanine levels in the blood are saturating the large, is mutated in Marfan syndrome, but this disorder is not
neutral amino acid transport protein in the nervous Marfan syndrome.
system (L-system), preventing other substrates from
entering the brain (such as tryptophan, tyrosine,
lysine, and leucine). This alters the ability of the 11 The answer is D: B6. Cystathionine β-synthase is a B6
brain to synthesize proteins, and leads to neurologi- requiring enzyme (the reaction is a β-elimination of
cal problems. Providing large amounts of these large, the serine hydroxyl group, followed by a β-addition of
neutral amino acids prevents saturation of the system homocysteine to serine; both types of reactions require
by phenylalanine, and can be used as a treatment, the participation of B6). In some mutations, the affin-
along with restricted phenylalanine diet, for children ity of the cofactor for the enzyme has been reduced, so
with this disorder. (See J Inherit Metab Dis. 2006 significantly increasing the concentration of the cofactor
Dec;29(6):732–738.) The developmental delay does will allow the reaction to proceed. The enzyme does not
not appear to be due to acidosis, lack of tyrosine, an require the assistance of B1, B2, B3 (niacin), or B12 to cata-
inhibition of hydroxylating enzymes, or inhibition of lyze the reaction.
neuronal glycolysis.
12 The answer is D: Glyoxylate. The boy has primary
10 The answer is E: Homocystine. The boy is exhibiting oxaluria type I, an autosomal recessive trait, which is
the symptoms of homocystinuria, usually caused by a defect in a transaminase that converts glyoxylate to
a defect in cystathionine β-synthase. Cystathionine glycine. If this transaminase is defective, glyoxylate will
β-synthase will condense homocysteine with serine to accumulate. The glyoxylate will then be oxidized to
form cystathionine. An inability to catalyze this reaction oxalate, which, in the presence of calcium, will precipi-
will lead to an accumulation of homocysteine, which will tate and form stones in the kidney. The metabolic path-
oxidize to form homocystine. The elevated serine can be way for glycine being converted to glyoxylate is shown
metabolized back into the glycolytic pathway. Methion- below, and the enzyme that catalyzes this reaction is
ine will not increase in blood as the homocysteine pro- the D-amino acid oxidase. Alanine, leucine, and lysine
duced is converted into homocystine. Phenylpyruvate metabolism do not give rise to oxalate.

CH3 H
O
H C C C
+ O–
OH NH4
Threonine
O
PLP CH3 C
Serine H
hydroxymethyl O2
H2O2
+
COO–
transferase NH4
PLP +
D-amino acid
O2 COO–
H2C NH3 H C O
Serine oxidase Oxalate
COO– –
FH4 N 5,N 10–CH2–FH4 COO
Glycine Transaminase Glyoxylate TPP
CO2

COO
– COO–
FH4 NAD+ Pyruvate Alanine
C O H C OH
N 5,N 10–CH2–FH4 NADH
CH2 C O
Glycine CO2 + H2O
+ cleavage CH2
NH4 CH2
CO2 enzyme
COO– CH2
α -Keto- COO–
glutarate α-Hydroxy-
β-ketoadipate

Answer 12

Chap15.indd 134 8/26/2009 4:30:23 PM

 Amino Acid Metabolism and the Urea Cycle 135
but will not lead to significantly elevated homocysteine.
13 The answer is B: Restriction of dietary methionine.
S-adenosyl homocysteine hydrolase is the enzyme that
The boy has cystinuria, elevated levels of cystine in the
converts S-adenosyl homocysteine to homocysteine
urine, due to a defect in a kidney transporter that
and adenosine; lack of its activity will lead to a reduc-
removes cystine from the urine and sends it back into
tion, not an increase, in homocysteine levels.
the blood. Due to this, the concentration of cystine
in the urine is higher than normal and reaches levels
close to its solubility limit. Cysteine is derived from
15 The answer is C: Tyrosine. The boy has the inherited
methionine, so a reduction in methionine levels will
disorder tyrosinemia type I, which is a defect in fumary-
reduce cysteine levels, which then leads to a reduction
lacetoacetate hydrolase, the last step in the degradation
in cystine levels. Increasing ethanol content will lead
pathway for tyrosine (see the figure below). In its acute
to dehydration, which will increase the concentration
form, this disorder will lead to liver failure and death
of cystine in the urine, leading to increased precipi-
within 1 year of life. The accumulation of intermediates
tation. This would also be the case if the urine were
in the tyrosine degradation pathway triggers apoptosis
acidified (acidification also reduces the solubility of
the cystine stones). Restricting glycine is not effective,
as glycine is not a precursor of cysteine biosynthesis.
Prescribing diuretics would force the boy to urinate +
NH3
more frequently, and would raise a risk for dehydra-
CH2 CH COO–
tion, which would lead to possible elevation of cystine
concentrations. C C
Phenylalanine

14 The answer is C: Cystathionine b-synthase. Cysta- PKU Phenylalanine hydroxylase

thionine β-synthase has a requirement of pyridoxal
+
phosphate, and in about 50% of the cases of defective NH3
synthase enzymes, increasing the concentration of B6 HO CH2 CH COO
–

can overcome the effects of the mutation on the enzyme.

While a defect in methionine synthase will lead to ele- C C
Tyrosine
vated homocysteine (see the figure below; cystathion-
ine β-synthase is enzyme 3 and methionine synthase is Tyrosinemia II Tyrosine aminotransferase
enzyme 1), this enzyme requires B12, not B6. A defect in PLP
N5, N10 methylene tetrahydrofolate reductase will also O
lead to elevated homocysteine, but that enzyme has a HO CH2 C COO
–

requirement for NADH, not vitamin B6. A defect in cys-

tathionase (another B6 requiring enzyme) will block the C C
degradation of cystathionine, which will accumulate, p-Hydroxyphenylpyruvate

CO2
N 5,N 10-methylene-FH4 Glycine OH
NADH
Serine
2 FH4
ATP C CH2 COO–
PPi, Pi
NAD+ 1 Methionine
N 5-methyl-FH4 B12 C
HO
Dimethyl glycine Homogentisate
SAM
Betaine R
Homocysteine
R CH3 Alcaptonuria Homogentisate oxidase
B6 S-adenosyl homocysteine
3 Adenosine
Serine
–
Tyrosinemia I Fumarylacetoacetate hydrolase
Cystathionine
O
B6
α-Ketobutyrate, NH3 – –
OOC CH CH COO CH3 C CH2 COO–
Cysteine
Fumarate Acetoacetate

Chap15.indd 135 8/26/2009 4:30:24 PM

 136 Chapter 15

of the hepatocytes, leading to complete liver failure. The or phenylalanine. The figure below indicates the
yellowing of the eyes (jaundice, due to accumulated biosynthetic pathway of DOPA and the catecholamines.
bilirubin) is a result of liver failure. None of the other
amino acids listed (alanine, tryptophan, histidine, and Phenylalanine
lysine) contribute to the formation of intermediates of phe BH4
the phenylalanine and tyrosine degradative pathways. hydroxylase
BH2

HO NH+3
16 The answer is A: Tryptophan. Most drugs used to treat CH O–
depression do so by elevating serotonin levels, and CH2 C
serotonin is derived from tryptophan (see the figure O
below). Tyrosine is the precursor for catecholamines, L–Tyrosine
while glutamate is the precursor of GABA. Histidine is tyrosine BH4
the precursor for histamine, while glycine itself acts as a hydroxylase BH2
neurotransmitter in the brain.
OH

+
HO NH+3
CH2 CH NH3 Nicotinamide moiety CH O–
– of NAD(P) CH2 C
COO
N O
H
Dopa
Tryptophan
PLP
O2 BH4 dopa
tryptophan hydroxylase decarboxylase CO2
H2O BH2
OH
HO +
CH2 CH NH3 Neurons HO
COO– CH2
N CH2 NH+3
H
5-Hydroxytryptophan Dopamine
Adrenal
O2
medulla
PLP CO2 DOPA decarboxylase dopamine Cu2+
β-hydroxylase
HO +
Vitamin C
CH2 CH2 NH3
OH
N HO
H
CH2
Serotonin CH NH+3
OH

Norepinephrine

17 The answer is C: Tyrosine. This patient has Parkinson phenylethanol- S-Adenosylmethionine

amine N-methyl-
disease, which is a problem with dopamine synthe- transferase S-Adenosylhomocysteine
sis in the substantia nigra. Dopamine is derived from
OH
tyrosine. Treatment with DOPA in the initial stages of
the disease provides relief from the symptoms. DOPA HO
cannot be synthesized from alanine, serine, tryptophan, CH2 CH3
+
CH NH2
OH

Epinephrine

Chap15.indd 136 8/26/2009 4:30:26 PM

 Amino Acid Metabolism and the Urea Cycle 137

18 The answer is D: 5-hydroxyindoleacetic acid (5-HIAA). producing epinephrine or norepinephrine (the VMAs
This patient has the classic presentation of a carci- are degradation products of these neurotransmitters,
noid tumor. This type of tumor secretes serotonin that also seen in the figure below). The symptoms do not
causes these classic symptoms. The breakdown prod- match a pheochromocytoma, particularly due to the
uct of serotonin is 5-hydroxyindoleacetic acid (5-HIAA, lack of increase in heart rate or blood pressure. Dop-
see the figure below). Elevated levels of 5-HIAA in the amine is depleted in Parkinson disease, not in this
urine confirms a high level of serotonin and the diag- condition. Cortisol levels would be high in Cushing
nosis of a carcinoid. VMA and/or catechols would syndrome, but not under these conditions.
be elevated if the patient had a pheochromocytoma

A B
+
CH2 CH NH3
HO
COO– OH
+
N HO CH CH2 NH3
H
Tryptophan
Norepinephrine
O2 BH4
tryptophan hydroxylase MAO SAM COMT
H2O BH2
+
NH4 SAH
HO +
CH2 CH NH3 HO CH3O
– OH O OH
COO +
N HO CH CH HO CH CH2 NH3
H
5-Hydroxytryptophan
Oxidation +
MAO
NH4
PLP CO2 DOPA decarboxylase
HO
OH
HO +
CH2 CH2 NH3 MAO-A HO CH COO–

N NH3 O Oxidation
SAM
H HO
CH2 C H SAH
Serotonin COMT

N
CH3O
5-hydroxyindole- OH
acetaldehyde
HO CH COO–
NAD+
NADH 3-Methoxy-4-hydroxymandelic acid
O (Vanillylmandelic acid, VMA)
HO
CH2 C O–

N
H
5-hydroxyindole
acetic acid (5-HIAA)

Panel A shows the generation of 5-HIAA from serotonin degradation, while panel B indicates the generation of VMA from catecholamine
degradation.

19 The answer is B: Tyramine. Tyramine is a degradation and excessive norepinephrine release does not occur.
product of tyrosine (decarboxylated tyrosine), which, However, if a patient is taking a monoamine oxidase
when elevated, will lead to norepinephrine release. inhibitor (MAOI), it is possible that tyramine does not
Tyramine is found in red wine and aged foods such as get degraded appropriately. MAOIs which covalently
certain cheeses. When ingested, tyramine is degraded modify (as opposed to being competitive inhibitors)
by monoamine oxidase to a harmless compound, the enzyme are very useful medications for atypical

Chap15.indd 137 8/26/2009 4:30:27 PM

 138 Chapter 15

depression that is unresponsive to other modalities. heme precursors in skin cells that are easily converted
Unfortunately, MAOIs have multiple interactions with to radical form by the energy in sunlight, and which
many other medications and foods. A high tyramine severely damage the cell. The drug the boy is taking
level leads to a greatly elevated blood pressure due to is metabolized via a cytochrome P450 system, which
the release of norepinephrine. Patients on MAOIs need is induced when the drug first enters the circulation.
to avoid foods high in tyramine, such as cheeses (aged Induction of P450 systems induces the synthesis of
and processed), red wine, caviar, brewer’s yeast, miso heme, leading to increased concentrations of the
soup, dried herring, and aged meats. MAOIs have no heme intermediates and an increased sensitivity to
effect on glycoproteins or cholesterol. the effects of these intermediates as induced by sun-
light. The anemia is due to reduced heme levels in
20 The answer is E: Heme synthesis. The boy has por- the red blood cells. This disorder is not due to defects
phyria, a reduced ability to synthesize heme. The in DNA repair, glycogen metabolism, or fatty acid
supersensitivity to the sun is due to the presence of metabolism.

Chap15.indd 138 8/26/2009 4:30:28 PM

 Chapter 16

Phospholipid
Metabolism
This chapter quizzes the reader on the biological (A) Dipalmitoyl phosphatidylcholine
roles of phospholipids, sphingolipids, and glycosa- (B) Palmitate containing ceramide
minoglycans. Diseases relating to these large (C) Sphingosine
molecules will be the focus of this chapter. (D) Sphingomyelin
(E) Diacylglycerol
QUESTIONS
Select the single best answer. 4 Considering the case in the previous question, the major
function of the suspension utilized to improve breath-
1 A patient presents with rapidly progressive weakness of ing is which of the following?
the lower extremities, loss of deep tendon reflexes, respi- (A) To allow oxygen exchange with red blood cells
ratory distress, and autonomic dysfunction following a (B) To facilitate carbon dioxide extraction from red
flulike illness. This disease is an autoimmune inflamma- blood cells
tory reaction to tissue made up chiefly of which of the
(C) To reduce surface tension at the air–water interface
following chemical structures?
(D) To stabilize the structure of lung cells
(A) High-density lipoproteins
(E) To facilitate blood flow through the lung
(B) Elastin
(C) Sphingolipids
(D) Glycoproteins 5 A 9-month-old child is taken to the pediatrician for leth-
(E) Glycogen argy and poor feeding. The physician notes a cherry-red
spot in the child’s retina. The baby seemed fine for the
2 The above patient is in the recovery phase of her illness. first three to six months, then began to have problems
She wants to “naturally” help her body recover using swallowing, overreacted to loud sounds, seemed to have
dietary methods. Which of the following foods is best in problems with her vision, and began losing muscle mass
providing the chemicals needed to regrow the affected and strength. Measurements of which two metabolites is
tissues? critical to correctly diagnose this disorder?
(A) Soybeans (A) GM2 and globoside
(B) Calves’ liver (B) GM2 and GM3
(C) Pork kidney (C) GM1 and globoside
(D) Green leafy vegetables (D) GM1 and GM2
(E) Potatoes (E) Globoside and sphingomyelin

3 A newborn infant had trouble breathing at birth. The 6 Considering the child described in the previous ques-
infant was 3 months premature. The physicians treated tion, a diagnosis of Sandhoff disease was made. This
the infant with a solution, which was directly injected results in a loss of which of the following enzymatic
into the lungs. Within seconds, the infant responded activities?
with much improved breathing. A major component of (A) Hexosaminidase A and Hexosaminidase C
this solution is which one of the following? (B) Hexosaminidase B and Hexosaminidase C
(C) Hexosaminidase A and Hexosaminidase B
(D) Hexosaminidase A and sphingomyelinase
(E) Hexosaminidase B and sphingomyelinase

139

Chap16.indd 139 8/27/2009 1:08:09 PM

 140 Chapter 16

7 Considering the child described in the last two questions, (A) Galactosylceramide
multiple enzymatic activities are lost. This is due to (B) Sulfatide
which of the following? (C) Glucosylceramide
(A) A common operon for the two genes contains a (D) Sphingomyelin
mutation in the promoter region (E) Ceramide
(B) An inactivating mutation in an activator for the lost
enzymatic activities
10 The sphingolipidoses, as a class, are most similar to
(C) A transcriptional activator is inactivated which one of the following disorders?
(D) A common mutated subunit is present in the mul- (A) Glucose-6-phosphate dehydrogenase deficiency
tiple activities
(B) von Gierke disease
(E) A transcriptional repressor is activated
(C) Zellweger syndrome
8 A 4-month-old infant is brought to the pediatrician for a (D) MELAS
variety of problems. The child is frequently irritable, small (E) I-cell disease
for age, vomits frequently, and displays hypotonia, as well
as hyperesthesia (auditory, tactile, and visual). Liver and 11 A child has been diagnosed with Tay–Sachs disease, in
spleen size are normal. As the child ages, his condition which a particular lipid accumulates within the lyso-
worsens, with rapid psychomotor deterioration, seizures, somes. The component of this lipid which cannot be
and blindness. This disorder is caused by an accumula- removed in the lysosome is which of the following?
tion of which of the following in neuronal lysosomes?
(A) Ceramide
(A) Galactosylceramide
(B) Sphingosine
(B) Sulfatide
(C) Fatty acid
(C) Glucosylceramide
(D) Glucose
(D) Sphingomyelin
(E) N-acetylgalactosamine
(E) Ceramide

9 A 6-month-old boy is brought to the pediatrician due 12 A depressed patient is prescribed lithium by his psy-
to a large stomach. The doctor noticed splenomegaly, chiatrist. The effect of lithium is to block the generation
with no pain. The boy was always tired and had anemia. of which of the following?
The boy also has thrombocytopenia and bruises easily. (A) Diacylglycerol
X-rays show a deformity of the distal femur, as shown (B) Inositol trisphosphate
below. This disorder is caused by an accumulation of (C) Inositol bisphosphate
which of the following in macrophage lysosomes? (D) Inositol phosphate
(E) Inositol

13 An alcoholic patient with advanced cirrhosis presents

with spur cell anemia. For virtually all cell types and
organelles, the phospholipid composition of the inner
and outer leaflets of the membrane is different. The spur
cell anemia is the result of the loss of one potential ben-
efit of such phospholipid asymmetry. Which of the fol-
lowing best explains this benefit?
(A) To vary the melting temperature of the membrane
(B) To represent all phospholipids species within the
membrane
(C) To mark cells for recognition by outside systems
(D) To distinguish between intracellular organelles
(E) To prevent fusion of intracellular organelles

14 Phosphatidylinositol contributes to phospholipid bilayer

asymmetry by being in the inner leaflet of membranes,
facing the cytoplasm of the cell. This is most likely due
to which of the following?

Chap16.indd 140 8/27/2009 1:08:09 PM

 Phospholipid Metabolism 141
(A) The hydrophobic nature of inositol is unstable 18 A 27-year-old woman sees her physician due to weakness
facing the cellular exterior and tiredness. She has tingling and numbness in her
(B) Inositol is very similar in structure to glucose and fingers and toes, loss of balance and falling, and blurry
could compete with glucose for binding of ligands vision, sometimes double vision. Her ophthalmologist
to the extracellular surface has diagnosed optic neuritis in her. An MRI of the brain
(C) Phosphatidylinositol acts as a substrate for intracel- shows “skip lesions.” The component that is primarily
lular processes defective in this patient is composed of which of the fol-
(D) Phosphatidylinositol binds to phosphatidylserine, lowing?
another inner leaflet specific phospholipid (A) Phospholipids and proteins
(E) Inositol interacts with intracellular actin, linking (B) Triacylglycerol and protein
the inner leaflet to a cell’s cytoskeleton (C) Phospholipids and triacylglycerol
(D) Gangliosides and protein
15 The use of proteoglycans in synovial fluid of joints is
(E) Triacylglycerol and gangliosides
advantageous due to the ability of the proteoglycans to
form which type of interactions with other components
of the fluid? 19 A woman has a history of premature miscarriages (three),
(A) Disulfide and ionic bonds thrombocytopenia, and several episodes of deep vein
(B) Hydrogen and ionic bonds thrombosis. She has a positive lupus anticoagulant but
(C) Covalent and ionic bonds does not have systemic lupus erythematosus (SLE).
Examination of the proteins in her blood should find
(D) Covalent and hydrogen bonds
antibodies directed against which of the following?
(E) Disulfide and hydrogen bonds
(A) Cytochrome c
16 Your 52-year-old male patient, an avid soccer player in (B) Phospholipids
his youth, who had several knee injuries, has been com- (C) DNA
plaining of knee pain for the past 6 months. The knees (D) RNA splicing proteins
are tender, stiff, and feel warm when touched. He wants (E) Ribosomes
long-term relief, not just short-term relief. You suggest
that the patient take which of the following to try and 20 An athlete presents to the ER with sudden pain in his
reduce the knee pain, for the long term? calf after hearing a “popping noise,” and inability to
(A) Aspirin push off with his toes when he tries to run. He gives
(B) Acetaminophen a history of having a “cortisol shot” in his heel area
(C) Sphingomyelin for Achilles tendonitis and he just finished a course
(D) Glucosamine of ciprofloxacin for chronic prostatitis. Physical exam
(E) Inositol reveals a mass in the superior posterior lower leg and
an inability to plantar flex his foot. Biopsy of the Achil-
17 Children with either I-cell disease or Hurler syndrome les tendon would be expected to reveal fibrotic areas,
show very similar clinical features. One method to dis- neovascularization, and an increase of which of the fol-
tinguish between the two is to find which of the follow- lowing in the extracellular matrix?
ing elevated in the blood? (A) Cholesterol
(A) Heparan sulfate (B) Glycosaminoglycans
(B) Short-chain dicarboxylic acids (C) Triglyceride
(C) Lysosomal hydrolases (D) Sphingosine
(D) Dermatan sulfate (E) High Density Lipoprotein (HDL)
(E) Cytochrome c

Chap16.indd 141 8/27/2009 1:08:09 PM

 142 Chapter 16

ANSWERS the type II cells within the lung have not yet begun
synthesizing surfactant, so the application of surfactant
1 The answer is C: Sphingolipids. This patient has the to the baby will allow this compound to be present until
classic symptoms of Guillain–Barré syndrome which is the type II cells begin their synthesis of this complex.
an inflammatory autoimmune neuritis wherein T-cells The major phospholipid in surfactant is dipalmitoyl
formed in response to a viral illness mistakenly attack phosphatidylcholine (DPPC), and it is complexed with
the myelin sheath of peripheral nerves. The myelin a number of small proteins (surfactant proteins A, B,
sheaths are composed primarily of sphingolipids and and C). While small amounts of sphingomyelin may be
phospholipids and do not contain high-density lipo- present in surfactant, DPPC is the major component.
proteins, elastin, glycogen, or a significant level of gly- The structure of DPPC is shown below.
coprotein. A view of demyelination is shown below.

Neuron O H2C O C (CH2)14 CH3

CH3 (CH2)14 C O CH O CH3
Myelin sheath +
H2C O P O CH2 CH2 N CH3
O– CH3

Dipalmitoyl phosphatidylcholine,
the major component of lung surfactant
Axon of
nerve fiber
A

4 The answer is C: To reduce surface tension at the air–water

Nerve fiber
Myelin
interface. The phospholipid–protein mixture of surfac-
tant interacts at the surface of lung cells, allowing expan-
B Nerve fiber
sion and contraction due to reducing surface tension at
the air–water interface (see the figure below). Surfactant
does not affect oxygen exchange with the red blood cells,
nor does it allow carbon dioxide removal from such cells.
C Surfactant does not stabilize lung cell structure (although
it is essential for the function of the lung cell), nor does
it facilitate blood flow through the lung.

D Inflated terminal sac

(alveolus)

Without lung surfactant,

An overview of demyelination. Panels A and B depict normal con- sac collapses. Ten times
ditions, whereas panels C and D show the slow disintegration of the normal pressure is Expiration Inspiration
myelin, resulting in demyelination and a loss of axonal function. needed for re-inflation.

Lung surfactant reduces Less pressure is needed

2 The answer is A: Soybeans. Foods considered the the surface tension of to re-inflate sac when
highest sources of sphingolipids include dairy and soy water (fluid) lining the surfactant is present.
surface of the alveolar
products. Foods highest in phospholipids include those sac, preventing collapse.
high in lecithin, such as eggs, soy, and wheat. Sphin-
The effect of lung surfactant
golipids and phospholipids are found mostly in neural
tissue. Other organs and muscle do not contain as high
a quantity of these lipids as do neural tissues.
5 The answer is A: GM2 and globoside. The cherry-
red spot is indicative of either Tay–Sachs disease (an
3 The answer is A: Dipalmitoyl phosphatidylcholine. The autosomal recessive disorder leading to a loss of hexo-
patient was treated with an artificial preparation of lung saminidase A [hex A] activity) or Sandhoff disease (an
surfactant, which reduces surface tension within the autosomal recessive disorder leading to a loss of both
lung at the air–water interface. In premature newborns, hexosaminidase A and B [hex B] activity). With just a

Chap16.indd 142 10/28/2010 8:02:53 PM

 Phospholipid Metabolism 143
loss of hex A activity, GM2 would accumulate. With a 6 The answer is C: Hexosaminidase A and Hexosaminidase
loss of hex B activity, globoside and GM2 would accu- B. In Sandhoff disease, both hex A and hex B activi-
mulate. Thus, by measuring the levels of GM2 and glo- ties are lost. The mutation in Sandhoff disease does not
boside, one can distinguish between Tay–Sachs and affect sphingomyelinase activity, and there is no hexo-
Sandhoff disease. A loss of either hex A or hex B would saminidase C activity. Sandhoff disease is one of many
not affect GM1 or GM3 degradation. which affect sphingolipid metabolism. An overview of
the sphingolipidoses is shown in the figure below.

CEREBROSIDE GANGLIOSIDE

Sandhoff XXX XXX

X
GM
disease Gangliosidosis

Tay-Sachs
Fabry XXX XXX
disease
disease (GM
Gangliosidosis)

Lactosyl XXX
ceramidosis
Sulfatide

Gaucher XXX XXX Krabbe disease

disease

Sphingomyelin
yelin
XXX

XXX

Niemann-Pick Metachromatic leukodystrophy

XXX
X
disease
Farber lipogranulomatosis

SPHINGOSINE
+
FATTY ACID

N-acetyl galactosamine Ceramide S Sulfate

Galactose N-acetyl neuraminic acid Enzymatic action
Glucose Phosphoryl choline XXX Metabolic block

Answer 6: A summary of the sphingolipidoses in diagrammatic form.

Chap16.indd 143 10/28/2010 8:02:55 PM

 144 Chapter 16

7 The answer is D: A common mutated subunit is present in degrading ceramide leads to Farber disease, a defect in
in the multiple activities. The hexosaminidase A gene ceramidase. Farber disease is similar to Krabbe disease,
encodes the hex A protein, and the hexosaminidase but often presents with hepatomegaly and splenomegaly.
B gene encodes the hex B protein. Hexosaminidase A See Table 16.1 in the next answer for a summary of all
activity requires a complex of hex A and hex B proteins; the sphingolipidoses and the material that accumulates
hexosaminidase B activity only requires a complex of within the lysosomes. Additionally, the figure associated
hex B proteins. Tay–Sachs disease is a defect in the hex with the answer to question 6 of this chapter depicts the
A protein, affecting only hex A activity. Sandhoff disease metabolic blocks of the sphingolipidoses.
is a defect in the hex B protein, which affects both hex
A and hex B activity, due to the sharing of a common 9 The answer is C: Glucosylceramide. The child has a form
subunit between the two proteins. hex A and hex B are of Gaucher disease, which is a defect in a glucosidase
not in an operon (which is only operative in bacteria); in which removes glucose from glucosylceramide. The
fact, the genes are on different chromosomes. There is an accumulation of glucosylcerebroside in the lysosomes
activating protein for hex A activity, but not hex B activ- leads to the observed symptoms. Defects in degrad-
ity (a loss of the activating protein is known as Sandhoff ing galactosylceramide lead to Krabbe disease, which
activator disease, with symptoms very similar to Tay– does not result in hepatomegaly and splenomegaly. A
Sachs disease). There are no mutations in transcriptional defect in degrading sulfatide leads to metachromatic
control proteins (either an activator or inhibitor) in Tay– leukodystrophy, which has different symptoms than
Sachs or Sandhoff disease. The interactions of the hex A what the child is experiencing. A defect in the degrada-
and hex B proteins are shown in the figure below. tion of sphingomyelin leads to Niemann–Pick disease,
with a different set of symptoms than that seen with
Sandhoff activator protein Gaucher disease. A defect in degrading ceramide leads
+ to Farber disease, a defect in ceramidase, with more
severe symptoms than those observed in Gaucher dis-
hexosaminidase A (α2 β2) ease. Table 16-1 summarizes the sphingolipidoses, the
Block in Sandhoff disease enzyme defect, and the material that accumulates. Uti-
Block in Tay–Sachs disease lize this table with the figure associated with the answer
GM2 Ceramide Glc Gal NAcGal to question 6 of this chapter for a thorough understand-
ing of the consequences of the sphingolipidoses.
Sialic acid
10 The answer is E: I-cell disease. The sphingolipidoses
Hexosaminidase A or B ( β4) and I-cell disease are both lysosomal storage diseases,
Block in Sandhoff disease whereas the other disorders listed do not involve
lysosomal dysfunction. Mitochondrial myopathy,
Globoside ceramide Glc Gal Gal NAcGal
encephalopathy, lactic acidosis, and stroke (MELAS) is a
Substrate specificities of hexosaminidase A and B, and the function mitochondrial disorder, and Zellweger’s is a disorder of
of the activator protein. Defects in the β-subunit inactivate both hex peroxisomal biogenesis. G6PDH (glucose-6-phosphate
A and hex B activities, leading to GM2 and globoside accumulation. dehydrogenase) deficiency and von Gierke disease are
A defect in Sandhoff activator protein also leads to GM2 accumulation, single gene mutations which do not alter lysosomal
as hex A activity is reduced. Defects in the α-subunit only inactivate function (although type II glycogen storage disease,
hex A activity, such that hex B activity toward globoside is unaffected. Pompe disease, is a lysosomal storage disease).
Glc, glucose; Gal, galactose; NAcGal, N-acetylgalactosamine.
11 The answer is E: N-acetylgalactosamine. Tay–Sachs is
8 The answer is A: Galactosylceramide. The child has a defect in hexosaminidase A, which removes the ter-
Krabbe disease, a mutation in a galactosidase, which minal N-acetylgalactosamine residue from ganglioside
cannot remove galactose from galactose cerebroside GM2, producing the free sugar and GM3. Hexosamini-
(an inability to break the bond between galactose and dase A does not cleave glucose, ceramide, sphingosine,
ceramide). The buildup of galactose–ceramide leads to or the fatty acyl component of ceramide from GM2; it is
the neuronal and muscle damage seen in the child. An specific for N-acetylgalactosamine.
inability to degrade a sulfatide would lead to metachro-
matic leukodystropy, which has very different symptoms 12 The answer is E: Inositol. Lithium primarily inhibits
than Krabbe disease. An inability to degrade glucosyl- the phosphatase which converts inositol phosphate to
ceramide leads to Gaucher disease, again, with a very free inositol, thereby disrupting the phosphatidylinositol
different disease progression than that seen with Krabbe cycle, leading to increased levels of the intermediates of
disease. A defect in the degradation of sphingomyelin the cycle, which are often signaling molecules. Lithium
leads to Niemann–Pick disease, with a different set of does not affect the generation of diacylglycerol, inosi-
symptoms than that seen with Krabbe disease. A defect tol trisphosphate (IP3), inositol bisphosphate (IP2), or

Chap16.indd 144 8/27/2009 1:08:15 PM

 Phospholipid Metabolism 145
Table 16-1. Defective enzymes in the gangliosidoses

Disease Enzyme Deficiency Accumulated Lipid

Fucosidosis α-Fucosidase Cer–Glc–Gal–GalNAc–Gal:Fuc H-isoantigen

Generalized gangliosidosis GM1-β-galactosidase Cer–Glc–Gal(NeuAc)–GalNAc:Gal GM1 ganglioside
Tay–Sachs disease Hexosaminidase A Cer–Glc–Gal(NeuAc):GalNAc GM2 ganglioside
Tay–Sachs variant or Sandhoff Hexosaminidase Cer–Glc–Gal–Gal:GalNAc Globoside plus GM2 ganglioside
disease A and B
Fabry disease α-Galactosidase Cer–Glc–Gal:Gal Globotriaosylceramide
Ceramide lactoside lipidosis Ceramide lactosidase Cer–Glc:Gal Ceramide lactoside
(β-galactosidase)
Metachromatic leukodystrophy Arylsulfatase A Cer–Gal:OSO3 3-Sulfogalactosylceramide
Krabbe disease β-Galactosidase Cer:Gal Galactosylceramide
Gaucher disease β-Glucosidase Cer:Glc Glucosylceramide
Niemann–Pick disease Sphingomyelinase Cer:P–choline Sphingomyelin
Farber disease Ceramidase Acyl: sphingosine Ceramide
NeuAc, N-acetylneuraminic acid; Cer, ceramide; Glc, glucose; Gal, galactose; Fuc, fucose: site of deficient enzyme reaction.

inositol phosphate (IP); it affects just the conversion of phosphatidylinositol cycle). As such, it must face
IP to free inositol and a phosphate. the cytoplasm of the cell such that when the inositol
phosphate derivatives are produced, such as IP3, they
13 The answer is C: To mark cells for recognition by outside can move to their target receptors to elicit a cellular
systems. By having different phospholipid composi- response. Inositol contains six hydroxyl groups and
tions of the inner and outer leaflets of membranes, one is a very hydrophilic molecule. Inositol’s structure is
can utilize phospholipid head groups (which face the quite different from glucose (there is no carbonyl group
aqueous phase of their leaflet) as markers for “inside” in inositol), so it is unlikely that glucose and inositol
and “outside” the membrane structure. For example, the would compete for binding to the same receptors. Phos-
exposure of phosphatidyl serine on the “outside” of red phatidylinositol does not bind to phosphatidylserine in
blood cells as is seen in spur cell anemia is a signal for the inner leaflet of membranes. Inositol also does not
the removal of the cells from circulation by the spleen, interact with the actin cytoskeleton.
as the serine residue should be facing the “inside” of the
red blood cell. Spur cells are large red blood cells cov- 15 The answer is B: Hydrogen and ionic bonds. The
ered with spikelike projections from preferential over- high concentration of negative charges provided by
expansion of outer membrane components, leading to a the proteoglycans attracts cations that create a high
spurlike shape. Movement of the phospholipid is a sig- osmotic pressure within cartilage, drawing water into
nal of cell aging. The melting temperature of the mem- this specialized connective tissue and placing the col-
brane is better determined by the fatty acid composition lagen network under tension. The water remains due
of the phospholipids, not the head group composition. to hydrogen bond formation with the proteoglycans. At
Not all phospholipids are represented in all membranes equilibrium, the resulting tension balances the swell-
(for example, cardiolipin is found almost exclusively in ing pressure caused by the proteoglycans. Cartilage can
the mitochondria). Assymetric phospholipid compo- thus withstand the compressive load of weight bearing
sitions do not distinguish one organelle from another and then re-expand to it previous dimensions when that
(that is primarily due to protein content), and assymetry load is relieved. Disulfide bonds and covalent bonds do
in phospholipid composition may promote fusion (ves- not play a role in proteoglycan stabilization of joints.
icles need to bud from and fuse with other membranes,
particularly in the Golgi apparatus). 16 The answer is D: Glucosamine. While aspirin and
acetaminophen may provide short-term relief, the
14 The answer is C: Phosphatidylinositol acts as a sub- use of glucosamine may help to rebuild the pro-
strate for intracellular processes. Phosphatidylinositol teoglycan layer in the knees, reducing the osteoar-
is used as the substrate to provide signaling mol- thritis (although medical studies are controversial
ecules in response to the appropriate stimuli (the concerning the use of glucosamine and glucosamine

Chap16.indd 145 8/27/2009 1:08:15 PM

 146 Chapter 16

sulfate, in terms of providing relief from joint pain). inclusion of glucosamine derivatives in three of the five
Sphingomyelin and inositol are not important compo- repeating disaccharide units.
nents of the cartilage in joints. Proteoglycans contain
long carbohydrate chains, which consist of repeat-
ing disaccharide units (see the figure below). Note the 17 The answer is C: Lysosomal hydrolases. In I-cell disease,
the lysosomal hydrolases are mistargeted and are excreted
from cells into the circulation. As the pH of the blood is
Hyaluronate above 7 and the pH optimum of these enzymes is around
COO– CH2OH 5, there is no activity of the hydrolases in blood. In Hurler
O O
H H H H syndrome, a defect in the degradation of mucopolysac-
O
charides, there is an accumulation of dermatan and hepa-
OH H H O HO H H ran sulfate in the urine, but not in the blood. Short-chain
dicarboxylic acids are produced with a defect in medium
H OH H NHCOCH3
chain acyl-CoA dehydrogenase, and cytochrome c release
Glucuronic β( N-acetyl-
into the cytoplasm of cells from mitochondria is the sig-
acid glucosamine
nal to initiate apoptosis.

Chondroitin-6-sulfate
COO
–
CH2OSO3
– 18 The answer is A: Phospholipids and proteins. The
O O woman is experiencing the symptoms of multiple sclero-
H H O HO H O sis, a demyelinating disease. In this disorder, the myelin
OH H H H H H sheath around nerves degenerates, eventually interfer-
ing with nerve conduction due to a lack of insulation
H OH H NHCOCH3 (see the figure below for a schematic representation of
Glucuronic β( N-acetyl- the myelin sheath in the central nervous system). The
acid galactosamine myelin sheath is composed primarily of phospholipids
and proteins. Triacylglycerol and gangliosides are not
Heparin found in the sheath.
–
H CH2OSO3
O O
H COO – H H H
O
OH H H OH H O

H OSO3– H NHSO3 –
Iduronic α( Glucosamine
acid

Keratan sulfate
–
CH2OH CH2OSO3
O O
HO H H O
O
H H H OH H H

H OH H NHCOCH3
Galactose β( N-acetyl-
glucosamine Oligodendroglial
cells

Dermatan sulfate Myelin

sheath
–
H O3S CH2OH Axon
O O
H COO– O O H O
OH H H H H H

H OH H NHCOCH3
Cytoplasm of Node of
Glucuronic β( N-acetyl- oligodendroglial cell Ranvier Mitochondrion
acid galactosamine
The oligodendroglial cells synthesize the myelin sheath found sur-
Repeating disaccharide units found in glycosaminoglycans. rounding the neurons in the central nervous system.

Chap16.indd 146 8/27/2009 1:08:15 PM

 Phospholipid Metabolism 147

19 The answer is B: Phospholipids. The woman has primary 20 The answer is B: Glycosaminoglycans. Fluoroquinolones
antiphospholipid syndrome (Hughes syndrome), in have been associated with spontaneous tendon rupture
which the body produces antibodies against its own yielding the classic histopathologic findings as described
phospholipids and protein/phospholipid complexes in the case. Other risk factors for Achilles tendon rup-
(the major one being an anticardiolipin antibody). These ture include steroid injections into the tendon, gout,
antibodies will bind to proteins involved in coagulation rheumatoid arthritis, and renal transplantation. During
and increase the risk of blood clots. Antibodies directed tendon degeneration, glycosaminoglycan synthesis is
against cytochrome c, DNA, RNA splicing proteins increased in the extracellular matrix material of the ten-
(which occurs in SLE), or ribosomes are not observed don. Cholesterol, HDL, and triglyceride have no func-
in this disorder. tion in the tendon rupture. In addition, sphingosine is
also not found in the extracellular matrix of the tendon.

Chap16.indd 147 8/27/2009 1:08:16 PM

 Chapter 17

Wholebody
Lipid Metabolism
This chapter quizzes the student on the flow molecular defect in this patient is present in which of
and storage of lipids (primarily cholesterol and the following proteins?
triglyceride) throughout the body. (A) HMG-CoA reductase
(B) AMP-activated protein kinase
QUESTIONS (C) Lecithin cholesterol acyltransferase
Select the single best answer.
(D) ABC1
(E) Cholesterol ester transfer protein
1 You have a patient whose blood work indicates high
total cholesterol and elevated liver enzymes. You 5 Current American Heart Association Guidelines indicate
place him on cholestyramine to lower his cholesterol. that an adult male should have HDL levels equal to or
Cholestyramine acts to lower cholesterol by inhibiting greater than 40 mg/dL. A necessary enzyme contribut-
which of the following enzymes/pathways? ing to HDL’s protective effect is which of the following?
(A) HMG-CoA reductase (A) CETP
(B) Hepatic cholesterol synthesis (B) LCAT
(C) Release of bile salts from the gall bladder (C) ACAT
(D) Enterohepatic circulation reabsorption of bile salts (D) AMP-activated protein kinase
(E) The production of chylomicrons (E) Protein kinase A

2 You have placed a patient on Pravachol pravastatin to 6 Many clinical labs report lipid values using a calculated
reduce her cholesterol. This class of drugs is effective value for LDL. This calculation estimates the cholesterol
due to a direct inhibition of which of the following? content in which of the following particles under fasting
conditions?
(A) Medium chain acyl-CoA dehydrogenase (MCAD)
(A) HDL
(B) HMG-CoA synthase
(B) LDL
(C) HMG-CoA reductase
(C) IDL
(D) Carnitine acyltransferase 1 (CAT-1)
(D) VLDL
(E) Citrate lyase
(E) Chylomicron

3 A knockout mouse was created in which the ability to 7 Statins are ineffective in lowering cholesterol levels in
create conjugated bile salts was greatly impaired. The individuals with homozygous familial hypercholester-
net result of this mutation in a mouse fed a normal diet olemia due to which of the following?
is which of the following?
(A) HMG-CoA reductase is resistant to statins
(A) Steatorrhea
(B) Statins cannot enter the liver cells
(B) Elevated levels of chylomicrons
(C) LDL receptors are nonfunctional
(C) Deficiency of B vitamins
(D) Reverse cholesterol transport is inoperative in these
(D) Reduced pH in the intestinal lumen patients
(E) Reduced secretion of pancreatic zymogens (E) LCAT is resistant to statin action

4 A patient has enlarged orange tonsils, hepatosplenom- 8 You see a patient who has steatorrhea, with very low lev-
egaly, loss of sensation in hands and feet, and cloud- els of chylomicrons and VLDL in the circulation. Circu-
ing of the corneas. His HDL levels are 18 mg/dL. The lating triglyceride levels are extremely low. Examination

148

Chap17.indd 148 8/27/2009 1:08:45 PM

 Whole-body Lipid Metabolism 149
of intestinal epithelial cells shows lipid-laden cells. A (A) LDL
possible enzymatic defect leading to these findings is (B) Oxidized LDL
which of the following? (C) Triglycerides
(A) LPL (D) HDL
(B) Apolipoprotein CII (E) Oxidized HDL
(C) MTTP
(D) LCAT 13 Your 27-year-old male patient, with a BMI of 34, has
(E) CETP a total cholesterol of 450 mg/dL and triglycerides of
610 mg /dL. He exhibits planar xanthomas and has
9 A type 1 diabetic who has neglected to take his insulin already had one angioplasty last year. This patient
for a few days displays both hyperglycemia and hyper- may be exhibiting a rare autosomal recessive disorder
triglyceridemia. The hypertriglyceridemia is due, in part, which generates a mutation in which of the following
to which of the following? proteins?
(A) Reduced synthesis of VLDL (A) LPL
(B) Reduced production of apolipoprotein CII (B) Apolipoprotein CII
(C) Increased fatty acid oxidation (C) Apolipoprotein E
(D) Reduced secretion of LPL (D) Apolipoprotein B100
(E) Increased synthesis of B100 (E) Apolipoprotein B48

14 A 44-year-old man displayed elevated cholesterol levels

10 A 12-year-old female presented with severe abdominal
and was prescribed a statin to reduce such levels. Statin
pain and was found to have a markedly elevated plasma
treatment has the potential to interfere with the synthe-
triglyceride concentration (750 mg/dL). A lipoprotein
sis of which of the following?
analysis revealed elevated levels of chylomicrons and
VLDL and reduced levels of HDL. Which protein might (A) Heme
be defective in this patient? (B) Coenzyme Q
(A) Apo B100 (C) Ketone bodies
(B) Apo B48 (D) Glycogen
(C) Apo CII (E) Dihydrobiopterin
(D) Pancreatic lipase
(E) LCAT 15 A 57-year-old man has been taking low-dose aspirin to
reduce his risk of heart disease. He adds phytosterols to
his daily regime for which of the following?
11 A 43-year-old woman presents with steatorrhea. Fecal
(A) To reduce circulating triglyceride levels
analysis reveals the presence of elevated triglycerides,
phospholipids, and cholesterol esters. Levels of car- (B) To reduce circulating cholesterol levels
bohydrate and protein were normal. Physical exam is (C) To reduce endogenous cholesterol synthesis
unremarkable. A possible defect in the release of which (D) To decrease insulin secretion
of the following would lead to these results? (E) To reduce fatty acid biosynthesis
(A) Cholecystokinin
(B) Insulin 16 Concerning the patient in the previous question, phy-
(C) Glucagon tosterols have the same general mechanism of action as
(D) Secretin which of the following drugs?
(E) Cortisol (A) Atorvastatin
(B) Ezetimibe
(C) Pravastatin
12 A 46-year-old man has been progressively having
trouble breathing while walking. Walking from his (D) Simvastatin
car to his office has become difficult, and he has to (E) Metformin
stop to rest along the way. He visits his physician,
who orders an angiogram, which shows blockage of 17 Macrophages found in arterial fatty streaks are often
major arteries leading to the heart. An initiating factor lipid filled and become foam cells. Such large amounts
for the development of the blockage is which of the of cholesterol uptake into these cells is possible due to
following? which of the following?

Chap17.indd 149 8/27/2009 1:08:46 PM

 150 Chapter 17

(A) Increased activity of ACAT within the foam cell indicated a substantial increase in the level of lipoprotein
(B) Increased activity of LCAT within the foam cell (a). Such a result would suggest which of the following?
(C) Constant SR-A1 expression on the cell surface (A) Substantially reduced risk for cardiovascular com-
(D) Upregulation of HMG-CoA reductase plications
(E) Increased activity of the LDL receptor (B) No change in risk for cardiovascular complications
(C) Increased risk for cardiovascular complications
18 A patient, 45-year-old male, BMI of 25, has had a his- (D) Increased platelet count
tory of elevated cholesterol (~300 mg/dL), with normal (E) Decreased platelet count
triglyceride levels (~125 mg /dL), and HDL levels
(48 mg /dL). Treatment with statins has reduced his
serum cholesterol to 180 mg /dL. The patient’s father 20 A 16-year-old male presents to you with xanthomas on
had a similar history and died of a heart attack at age 48. the extensor tendons of the hand and Achilles tendon
A potential mutation in this patient would be in which and arthritis of the knees. He has had one previous
of the following proteins? heart attack, despite normal cholesterol levels. Further
(A) LCAT analysis of his serum showed greatly elevated levels of
(B) CETP plant sterols. The molecular defect in this patient is most
(C) ABC1 likely in which of the following proteins?
(D) Apo B100 (A) Apo B100
(E) LDL receptor (B) Apo B48
(C) ABC1
19 A patient sees his or her physician for continuing treat- (D) ABCG5
ment of hypercholesterolemia. Recent blood work has (E) MTTP

Chap17.indd 150 8/27/2009 1:08:46 PM

 Whole-body Lipid Metabolism 151

ANSWERS oxidation), CAT-1 (required for acyl-CoA transport

into the mitochondria), or citrate lyase (needed to
1 The answer is D: Enterohepatic circulation reabsorption provide acetyl-CoA in the cytoplasm). The reactions
of bile salts. Because of the elevated liver enzymes required to produce HMG-CoA are shown below.
(suggestive of liver damage), a statin would be relatively
contraindicated in this patient, as a potential side effect O
of statins is liver damage. Cholestyramine would be a CH3 C SCoA
reasonable alternative to statins. Cholestyramine is one Acetyl CoA
of the “bile acid binders” and prevents the reabsorption O
of bile salts. Since cholesterol is the precursor of bile CH3 C SCoA
salts, and 95% of bile salts are usually reabsorbed back CoA-SH
into the enterohepatic circulation, losing bile salts in O O
the feces would require increased synthesis of bile salts,
CH3 C CH2 C SCoA
thereby reducing the levels of free cholesterol in the
Acetoacetyl CoA
body. Statins work by inhibiting HMG-CoA reductase.
Cholestyramine does not reduce hepatic cholesterol O
HMG-CoA
synthesis, inhibit the release of bile salts, or interfere synthase CH3 C SCoA
with the production of chylomicrons. Its sole action is CoA-SH
in the lumen of the intestine, where it binds the bile
salts so that they cannot be resorbed and sent back to O
the liver. The enterohepatic circulation is diagrammed C O–
b-hydroxy-
below. CH2
b-methyl-
CH3 C OH glutaryl CoA
CH2 (HMG-CoA)

C
Liver
O SCoA
2NADPH + 2H+
HMG-CoA STEP INHIBITED
2NADP+
Bile reductase BY STATINS
Pancreas Stomach CoA-SH
salts
O
Gall-
bladder C O–
Common CH2
bile duct
CH3 C OH
Enterohepatic CH2
circulation
carrying CH2OH
bile salts
Mevalonate

Ileum
95%
5% 3 The answer is A: Steatorrhea. The primary reason for
Feces synthesizing conjugated bile acids is to lower the pKa of
the acid, so that a higher percentage of the acid will be
2 The answer is C: HMG-CoA reductase. The first ionized in the intestine. The greater a bile acid is ionized,
stage of cholesterol synthesis leads to the produc- the more efficient the emulsification is for the digestion
tion of the intermediate mevalonate. Two molecules of the triglyceride. Without conjugation with glycine or
of acetyl-CoA condense to form acetoacetyl-CoA taurine, the pKa of the bile salts is about 6.0; at a pH of
which condenses with another acetyl-CoA to form 6.0, only 50% of the bile salts will be ionized in the intes-
β-hydroxymethylglutaryl-CoA (HMG-CoA). HMG- tinal lumen, which would produce inefficient triglyceride
CoA synthase catalyses this step. Next, HMG-CoA digestion, and the triglyceride content of the stool would
reductase catalyzes the reduction of HMG-CoA increase. By reducing the pKa to 4.0 (conjugated with
to mevalonate. Statins (the class of drugs to which glycine) or 2.0 (conjugated with taurine), greater than
pravastatin belongs) directly inhibit HMG-CoA 99% of the bile acids will be ionized, and triglyceride
reductase, so mevalonate cannot be formed and cho- digestion will be maximal. If an inability to conjugate the
lesterol synthesis cannot continue. Statins do not bile acids leads to inefficient triglyceride digestion, then
inhibit the enzymes MCAD (required for fatty acid intestinal chylomicron formation will be reduced, not

Chap17.indd 151 8/27/2009 1:08:46 PM

 152 Chapter 17

elevated (due to reduction of lipid uptake into the entero- acids will not affect the pH of the intestinal lumen, nor
cyte). Transport of the water soluble B vitamins into the will it affect the secretion of zymogens from the pancreas
intestinal cells is not dependent on lipid digestion, as is to the intestine. The reactions involved in the conjuga-
fat-soluble vitamin absorption. The conjugation of bile tion of the bile acids are shown below.

Cholic acid
ATP
CoASH

AMP +PPi

O
C SCoA
OH
CH3

CH3

HO OH
Cholyl CoA
pKa 6

+ +
H3N CH2 CH2 SO3– H3N CH2 COO–

Taurine CoASH CoASH Glycine

O O
C SO3– C
HO N HO N COO–
H H
CH3 CH3

CH3 CH3

HO OH HO OH
Taurocholic acid Glycocholic acid
pKa 2 pKa 4

4 The answer is D: ABC1. The patient has Tangier disease, 5 The answer is B: LCAT. HDL is protective, in part, due
which is a defect in the ATP-binding cassette protein 1 to its ability to remove excess cholesterol from cell mem-
(ABC1), a transporter in cell membranes which allows branes and return it to the liver. In order to accomplish
cholesterol efflux from the membrane into the HDL par- this, the cholesterol, after transport to the HDL particle
ticle. Once inside the HDL particle, the cholesterol is via the participation of ABC1, needs to be trapped within
trapped through esterification into a cholesterol ester. the core of the HDL particle, and this is accomplished by
The HDL particle can then return the cholesterol to the esterification and converting the cholesterol to a choles-
liver for further recycling. The defect in the patient is terol ester. LCAT (lecithin cholesterol acyl transferase) is
not in HMG-CoA reductase (required for the biosynthe- the enzyme that creates a cholesterol ester. The reaction,
sis of cholesterol), the AMP-activated kinase (a regula- on page 153, is the transfer of a fatty acid from phos-
tor of HMG-CoA reductase), LCAT (lecithin-cholesterol phatidyl choline (lecithin) to cholesterol, creating the
acyltransferase, the enzyme which esterifies cholesterol cholesterol ester and lysophosphatidyl choline. ACAT
in the HDL particle), or CETP (cholesterol ester trans- (acyl-CoA cholesterol acyl transferase) creates choles-
fer protein, a protein which exchanges HDL cholesterol terol esters in cells, but not in the HDL particles. CETP
esters for VLDL triglyceride). exchanges HDL cholesterol esters for VLDL triglyceride.

Chap17.indd 152 8/27/2009 1:08:47 PM

 Whole-body Lipid Metabolism 153
Protein kinase A is not involved in cholesterol transfer olemia (FH) is a mutation in the LDL receptor, mak-
throughout the body. The AMP-activated protein kinase ing the receptor unable to bind LDL. In homozygous
is not utilized in HDL action. The LCAT reaction is familial hypercholesterolemia, both LDL receptor genes
shown below. are mutated, and the LDL receptors are nonfunctional.
Upregulating nonfunctional LDL receptors will not lead
H
O to a reduction of LDL in the circulation, so such indi-
H C O C R1 viduals are resistant to statin action. FH is not due to a
O
HC O C R2
resistant HMG-CoA reductase, nor an inability of sta-
O tins to reach their target. FH is not related to reverse
+
HC O P O CH2CH2N(CH3)3 cholesterol transport, nor to LCAT. A diagram of recep-
H
O–
tor-mediated endocytosis, indicating the role of the
Lecithin (PC)
receptor, is shown below.

LDL particle Apo B-100

Cholesterol ester
LDL receptor

HO
Cholesterol

LCAT Receptor-mediated
endocytosis

O
Endosome
R2 C O
Cholesterol ester Golgi
complex
O Lysosome
H
HC O C R1
Cholesterol Amino acids
HC OH Fatty acids
LDL receptor
O synthesis
+ Cholesterol
HC O P O CH2CH2N(CH3)3 ester droplet
H
O–
Nucleus Endoplasmic
Lysolecithin reticulum

6 The answer is D: VLDL. Under fasting conditions, the

total cholesterol measured will be the sum of the choles-
8 The answer is C: MTTP. The patient has abetalipo-
terol in the HDL particles, the LDL particles, and VLDL.
proteinemia, an absence of apo B-containing proteins
Chylomicrons should be nil under fasting conditions.
in the circulation. This leads to low chylomicron
The total cholesterol is measured, as are HDL and trig-
and VLDL levels. The problem is the synthesis of the
lycerides. Since the VLDL is the primary triglyceride
chylomicrons and VLDL, both of which require the
carrier under these conditions, the cholesterol content
activity of the microsomal triglyceride transfer protein
of the VLDL is estimated to be 20% that of the triglyc-
(MTTP). In the absence of MTTP activity, triglycer-
eride content. Thus, the formula for calculating LDL
ides cannot be transferred to the core particle as it is
values is LDL = total cholesterol – HDL – [(TG)/5].
being synthesized, leading to little, if any, synthesis of
these particles. The intestinal cells become laden with
7 The answer is C: LDL receptors are nonfunctional. Sta- lipids obtained from the diet and those which cannot
tins are effective in lowering circulating cholesterol lev- be exported due to the inability to produce chylomi-
els due to a series of events. First, the statins inhibit crons. Mutations in LPL or apolipoprotein CII will not
HMG-CoA reductase, reducing intracellular synthesis interfere with chylomicron or VLDL synthesis; muta-
of cholesterol. The reduced cholesterol levels in the tions in those proteins would lead to an inability to
cell then upregulate the synthesis of LDL receptors, remove triglyceride from those circulating particles.
which remove LDL from circulation, thereby reducing Deficiencies in LCAT or ABC1, which are related to
circulating cholesterol levels. Familial hypercholester- HDL metabolism, would not affect the synthesis of

Chap17.indd 153 8/27/2009 1:08:48 PM

 154 Chapter 17

chylomicrons or VLDL. A schematic of MTTP action of insulin, LPL levels are low, and the particles have a
is shown below. longer half-life in circulation due to the reduced rate of
digestion, which contributes to hypertriglyceridemia. If
ER Lumen there were reduced synthesis of VLDL, triglycerides in
the circulation would be reduced, not increased. Insulin
Apo B-48 ApoB Larger does not alter the rate of apolipoprotein CII production.
particle ApoB To Golgi The release of insulin decreases fatty acid oxidation
particle for maturation
MTP MTP and secretion (promoting fatty acid synthesis), but if increased fatty
acid oxidation did occur, then triglycerides would not
LIPID TG accumulate in the circulation. Insulin also does not alter
Ribosome Cytoplasm the synthesis of apolipoprotein B100 in the liver, which
is required for VLDL synthesis.
A model of microsomal triglyceride transfer protein (MTTP) action.
MTTP is required to transfer lipid to apo B48 as it is synthesized, and 10 The answer is C: Apo CII. A lack of apolipoprotein
to transfer lipid from the cytoplasm to the lumen of the endoplasmic CII would mean that lipoprotein lipase could not be
reticulum as the particle (chylomicrons in the intestine, and VLDL in activated, and the triglyceride in both chylomicrons and
the liver) is being synthesized. VLDL would be unable to be digested. This would lead to
elevated levels of these particles, and a very high serum
triglyceride level. Since VLDL is not being converted to
9 The answer is D: Reduced secretion of LPL. Insulin IDL or LDL cholesterol levels are not elevated. Defects in
release stimulates the secretion of lipoprotein lipase either apo B100 or apo B48 would lead to a loss of either
(LPL) from fat and muscle cells such that the capillaries VLDL or chylomicrons, which is not observed. A defect
infiltrating these tissues have the lipase bound to extra- in pancreatic lipase would lead to steatorrhea, as the
cellular matrix material. Then, as the triglyceride-rich dietary triglycerides would not be able to be digested. A
particles move through the tissues, they bind to LPL defect in LCAT would affect HDL metabolism, but not
via apolipoprotein CII, and the triglyceride is digested triglyceride metabolism. An overview of the functions of
and the fatty acids used by the tissues. In the absence the lipoproteins is presented in Table 17-1.

Table 17-1. Characteristics of the major apoproteins

Primary Tissue Molecular Mass Lipoprotein

Apoprotein Source (Daltons) Distribution Metabolic Function

Apo A-1 Intestine, liver 28,016 HDL (chylomicrons) Activates LCAT; structural component
of HDL
Apo A-II Liver 17,414 HDL (chylomicrons) Unknown
Apo A-IV Intestine 46,465 HDL (chylomicrons) Unknown
Apo B-48 Intestine 264,000 Chylomicrons Assembly and secretion of chylomi-
crons from small bowel
Apo B-100 Liver 540,000 VLDL, IDL, LDL VLDL assembly and secretion;
structural protein of VLDL, IDL, and
LDL; ligand for LDL receptor
Apo C-1 Liver 6,630 Chylomicrons, VLDL, Unknown; may inhibit hepatic uptake
IDL, HDL of chylomicron and VLDL remnants
Apo C-II Liver 8,900 Chylomicrons, VLDL, Cofactor activator of lipoprotein lipase
IDL, HDL (LPL)
Apo C-III Liver 8,800 Chylomicrons, VLDL, Inhibitor of LPL; may inhibit hepatic
IDL, HDL uptake of chylomicrons and VLDL
remnants
Apo E Liver 34,145 Chylomicron remnants, Ligand for binding of several lipopro-
VLDL, IDL, HDL teins to the LDL receptor, to the LDL
receptor-related protein (LRP) and
possibly to a separate apo-E receptor
Apo(a) Liver Lipoprotein “little” Unknown
a (Lp(a))

Chap17.indd 154 8/27/2009 1:08:50 PM

 Whole-body Lipid Metabolism 155

11 The answer is D: Secretin. Secretin is released from the 13 The answer is C: Apolipoprotein E. The patient has dys-
intestine when food enters, and it signals the pancreas betalipoproteinemia, a mutation in apolipoprotein E,
to release a watery mixture of bicarbonate into the intes- such that the patient exhibits the rare E2 form instead
tine, in order to help neutralize the acid present from of the normal E3 form. Apolipoprotein E has affinity for
the digestion that occurred in the stomach. If the pH the LDL receptor and the LDL receptor-related protein
of the intestinal lumen is too low, the bile salts will not and, as such, is important for chylomicron remnant and
be ionized, and emulsification of the dietary fats will be IDL uptake from the circulation by the liver. With the
inefficient, as will be the formation of mixed micelles to homozygous E2 form, binding of the particles to their
allow intestinal absorption of fat components. Digestion receptors is weak, and the particles circulate longer than
of carbohydrates and protein is not dependant on bile normal, contributing to the high cholesterol and triglyc-
salt ionization. A loss of cholecystokinin would result eride levels seen in the circulation. Only about 10% of
in no pancreatic zymogens being secreted, and there the individuals who are homozygous for E2 will develop
would be no digestion of carbohydrates, proteins, or this condition, and in those, obesity (BMI of 34) is a key
lipids within the intestine. A lack of insulin secretion, factor which links the condition to the mutation. This
or glucagon secretion, does not affect digestion in the disorder is not a problem with lipoprotein lipase (LPL)
intestinal lumen. Cortisol secretion also does not alter digesting triglycerides from particles, so neither LPL nor
intestinal digestion of nutrients. apo CII is defective. As both chylomicrons and VLDL
are produced, it is not a defect in either apo B48 or B100
12 The answer is B: Oxidized LDL. Oxidized LDL is taken production or function.
up by macrophages, which eventually turn into foam
cells in the development of an atherosclerotic plaque. 14 The answer is B: Coenzyme Q. Coenzyme Q is derived
The higher one’s LDL levels are, the more likely that from isoprene units, which are produced in the path-
oxidized LDL will form, leading to plaque formation. way of cholesterol biosynthesis, after the HMG-CoA
The receptor which recognizes and takes up oxidized reductase step. If HMG-CoA reductase is inhibited (as
LDL, SR-A1, is not downregulated, so the macrophage it is by statins), then the production of the isoprenes is
has an unlimited capacity to take up and store the oxi- also reduced, and both Coenzyme Q and dolichol lev-
dized LDL. Plaque formation does not occur due to els could become limiting. The biosynthesis of heme,
elevated levels of nonoxidized LDL, HDL of any form, ketone bodies, glycogen, or dihydrobiopterin is not
or triglycerides. A cartoon depiction of a normal and an dependent on isoprene units.
atherosclerotic artery is shown below.
Atherosclerosis: The consequence of
high cholesterol
15 The answer is B: To reduce circulating choles-
terol levels. Phytosterols interfere with cholesterol
absorption in the intestine (through blockage of choles-
Normal
artery
terol incorporation into the mixed micelles, which are
When the level of
cholesterol in the
necessary for intestinal epithelial cells to absorb dietary
Outer bloodstream is cholesterol), thereby leading to a reduction in circulat-
layer normal, arterial
walls remain ing cholesterol levels. The phytosterols do not interfere
smooth and with the biosynthesis of cholesterol, nor do they alter
slippery.
the secretion of insulin. Phytosterols are also not capa-
ble of altering the rate of fatty acid biosynthesis, nor do
Lining they affect circulating triglyceride levels. The effect of
phytosterols is specific for the inhibition of cholesterol
Muscle
layer absorption from the intestine.

Clogged 16 The answer is B: Ezetimibe. Ezetimibe reduces cir-

artery When cholesterol
levels are high, culating cholesterol levels by blocking cholesterol
excess cholesterol absorption in the intestine, which is similar to the
concentrates in
the walls of mechanism of action of phytosterols. Atorvastatin is
arteries, a statin, and its mechanism of action is inhibition of
thereby
“LDL” reducing HMG-CoA reductase. Pravastatin is also a statin and
cholesterol blood flow. works as does atorvastatin. Simvastatin is yet another
statin. Metformin is a lipid- and glucose-lowering drug
Foam cells
which works via activation of the AMP-activated pro-
Plaque
tein kinase and does not alter cholesterol absorption

Chap17.indd 155 8/27/2009 1:08:51 PM

 156 Chapter 17

Table 17-2. Mechanism(s) of action and efficacy of lipid-lowering agents

Percentage Change in Serum Lipid Level
(monotherapy)
Total LDL HDL
Agent Mechanism of Action Cholesterol Cholesterol Cholesterol Triacylglycerols

Statins Inhibit HMG-CoA ↓15%–60% ↓20%–60% ↑5%–15% ↓10%–40%

reductase activity
Bile acid resins Increase fecal excretion of ↓15%–20% ↓10%–25% ↑3%–5% Variable, depending on
bile salts pretreatment level of
triacylglycerols (may
increase)
Niacin Activates LPL; reduces ↓22%–25% ↓10%–25% ↑15%–35% ↓20%–50%
hepatic production of
VLDL; reduces catabolism
of HDL
Fibrates Antagonizes PPAR-α, ↓12%–15% Variable, ↑5%–15% ↓20%–50%
causing an increase in depending
LPL activity, a decrease in on pretreat-
apoprotein C-III produc- ment levels
tion, and an increase in of other
apoprotein A-I production. lipids
Ezetimibe Reduces intestinal absorp- ↓10%–15% ↓15%–20% ↑1%–3% ↓5%–8% if triacylglyc-
tion of free cholesterol erols are high pretreat-
from the gut lumen ment
LPL, lipoprotein lipase; LDL, low-density lipoprotein; HDL, high-density lipoprotein; triacylglycerols, triglycerides; PPAR, peroxisome proliferator-
activated receptor.
Adapted from Circulation. Grundy SM, Becker D, Clark LT etal. 2002;106:3145–3457.

in the intestine. Table 17-2 summarizes the action of heart attacks are common in such patients before the
cholesterol lowering drugs. age of 50. This condition is treated with statins, which
reduce endogenous cholesterol synthesis, thereby lead-
17 The answer is C: Constant SR-A1 expression on the cell ing to an upregulation of LDL receptors, which allows
surface. The macrophages take up oxidized LDL for normal LDL uptake from the circulation. Muta-
using a scavenger receptor, SR-A1, which is not down- tions in LCAT (familial LCAT deficiency) are rare and
regulated. This allows the receptor to remain on the cell do not often lead to premature atherosclerotic disease
surface and to constantly import oxidized LDL into the (although some exceptions are noted), but do lead to
cell. The high levels of cholesterol in the foam cells is kidney and corneal damage due to large amounts of
not due to a change in activity of ACAT or LCAT (which unesterified cholesterol present in those tissues. HDL
is found in HDL particles), nor is there upregulation level in these individuals is usually less than 10 mg/
of HMG-CoA reductase (which would produce more dL, which is not observed in our patient. Mutations in
endogenous cholesterol, which is unlikely since the cell CETP (cholesterol ester transfer protein) lead to eleva-
is filled with cholesterol and cholesterol esters). Mac- tions in HDL levels and would not be responsive to
rophages do not use the LDL receptor for importing statin action. Mutations in ABC1 lead to Tangier dis-
oxidized LDL. ease, which would lead to a reduction in HDL levels,
which is not seen in this patient. A deficiency in apo
18 The answer is E: LDL receptor. The patient is heterozy- B100 would impair VLDL synthesis and would actu-
gous for a mutation in the LDL receptor (familial hyper- ally reduce circulating LDL levels since there is less
cholesterolemia). This condition leads to elevated LDL VLDL present to be converted to LDL. The diagram on
levels since there are insufficient receptors available page 157 depicts potential problems which result from
to remove LDL from the circulation. If left untreated, defects in the LDL receptor.

Chap17.indd 156 8/27/2009 1:08:53 PM

 Whole-body Lipid Metabolism 157

Gene 19p13 Cerebral

atherosclerosis
with stroke

Position 13

Increased blood
p Mutation of cholesterol and
gene 19p13 atherosclerosis

Coronary artery
q atherosclerosis
with coronary
occlusion and
Chromosome 19 Defective lipoprotein receptor; myocardial infarction
cannot capture cholesterol for
excretion into bile
General
atherosclerosis
with aortic aneurysm

Answer 18: Potential results of mutations within the LDL receptor.

19 The answer is C: Increased risk for cardiovascular complica- the bile duct, where they will be released along with
tions. Lipoprotein (a) is an LDL particle with a covalently the bile during fat digestion. In the absence of activity
linked apoprotein A (linked to apoprotein B100) attached of either ABCG5 or ABCG8, the phytosterols are pack-
to the particle. The presence of this unusual lipoprotein aged into chylomicrons and are eventually delivered to
particle has been positively correlated with the presence the liver, where they are packaged into VLDL. While
of heart disease. The role of this particle is unknown, but human cells cannot utilize phytosterols, their increased
may be related to coagulation, since apoprotein A resem- presence interferes with the synthesis of cholesterol and
bles plasminogen in structure. Lp (a) levels do not regu- the normal cholesterol recycling within the affected
late the levels of platelets in the circulation. patient. Patients with this disorder develop premature
coronary artery disease. It has been hypothesized that
20 The answer is D: ABCG5. The patient has sitoster- the high levels of plant sterols in the circulating lipopro-
olemia, an accumulation of plant sterols (phytosterols) tein particles accelerate the deposition of these sterols in
in cells and tissues. Under normal conditions, phy- the walls of the arteries, promoting atherosclerosis. This
tosterols can diffuse into the epithelial cells, but they disorder is not due to mutations in either apo B100 or
are actively transported back into the intestinal lumen apo B48, as both VLDL and chylomicrons are synthe-
by an ABC-cassette (ATP-binding) containing protein, sized normally in the patient. The defect is not in ABC1,
ABCG5 (the other protein responsible for phytosterol as the patient does not display the symptoms of Tangier
efflux is ABCG8).Those sterols which make it to the disease. The defect is also not in MTTP, as a defect in
liver are exported by the same proteins in the liver to that protein leads to abetalipoproteinemia.

Chap17.indd 157 8/27/2009 1:08:53 PM

 18
Chapter 1

Purine Structure
Protein
and Function
Pyrimidine
Metabolism
The questions in this chapter will test ones (A) Adenine
knowledge concerning de novo and salvage (B) Thymine
pathways related to nucleotide metabolism, as (C) Uracil
well as the relevance of these pathways to human (D) Cytosine
disease, and the treatment of human disease. (E) Ribose-5-phosphate

QUESTIONS 2 Your 60-year-old female patient has psoriasis and has

been treated with methotrexate for several years. She has
Select the single best answer.
no other medical problems and her preventive screen-
1 Your 56-year-old male patient presents with intense ings, including fecal occult blood tests and colonoscopy,
redness, heat, and pain over his right great toe at the have all been normal. She has developed an anemia.
metatarsophalangeal joint. Fluid from this joint shows Which of the following would you expect to find when
bifringent crystals. An X-ray of the foot is shown below. working up her anemia?
This disease is caused by the degradation of an excessive (A) A macrocytic anemia
amount of which of the following? (B) A microcytic anemia
(C) Thalassemia
(D) Spherocytes
(E) A low vitamin B12 level

3 A researcher wants to develop a method of labeling

purines with 15N for use in future spectroscopic stud-
ies. Purine synthesis will be done in a test tube using
only the enzymes necessary to synthesize purines via
the de novo pathway. Which starting materials should
be labeled with the heavy nitrogen in order to maximize
15
N incorporation into purines?
(A) Aspartate, glycine, and glutamate
(B) Aspartate, glycine, and N5-formimino tetrahydro-
folate
(C) Asparagine, glycine, and glutamine
(D) Asparagine, glutamate, and glutamine
(E) Aspartate, glycine, and glutamine

4 A patient has been recently diagnosed with colorectal

cancer. The physician treats the patient with a combina-
tion of chemotherapeutic drugs, one of which is 5-fluo-
rouracil (5-FU). 5-FU is effective as an anticancer drug
because it inhibits which one of the following enzymes?

158

Chap18.indd 158 8/26/2009 4:32:34 PM

 Purine and Pyrimidine Metabolism 159
(A) Dihydrofolate reductase 9 Your patient has sickle cell disease and is being treated
(B) Thymidylate synthase with hydroxyurea. After 2 weeks on the drug, you find
(C) Amidophosphoribosyl transferase greatly reduced levels of most blood cell types, and the
(D) 5′-phosphoribosyl 1′-pyrophosphate (PRPP) syn- patient is removed from the drug to allow his blood cell
thetase counts to stabilize. One potential reason for this side
(E) UMP synthase effect of hydroxyurea treatment is its ability to alter the
synthesis of which of the following metabolites?
5 A patient exhibits fasting hypoglycemia and lactic acido- (A) N5-methyltetrahydrofolate
sis under fasting conditions. Hepatomegaly is also evi- (B) 5′ phosphoribosyl 1′ amine
dent. A glucagon challenge only releases about 10% of (C) PRPP
the expected level of glucose from the liver. The patient (D) Adenosylcobalamin
has also developed gout due to an increase in the levels (E) dUMP
of which of the following metabolites?
(A) PRPP
(B) Glutamine 10 An 18-month-old infant has had a history of recurrent
(C) ATP bacterial and viral infections. The child has failure to
(D) NADH thrive, developmental delay, and tremors. Physical exam
shows a lack of peripheral lymphoid tissue. Blood work
(E) dTTP
shows lymphopenia, but normal levels of B-cells and
circulating immunoglobulins. This child most likely has
6 A 6-month-old infant is seen by the pediatrician for
a defect in which of the following enzymes?
developmental delay. Blood work shows megaloblastic
(A) Hypoxanthine guanine phosphoribosyltransferase
anemia, although measurements of B12 and folate are in
(HGPRT)
the high normal range. Urinalysis demonstrates, upon
standing, the formation of a crystalline substance. Sup- (B) Adenine phosphoribosyltransferase (APRT)
plementation of the child’s diet with uridine reversed (C) Adenosine deaminase (ADA)
virtually all of the clinical problems. The crystalline (D) Adenosine kinase
substance was most likely composed of which of the (E) Purine nucleoside phosphorylase
following?
(A) Uracil 11 Considering the child in the previous question, which
(B) Thymine one of the following metabolites would you expect to
(C) Orotate accumulate in the thymocytes?
(D) Aspartate (A) dCTP
(E) Cytosine (B) dTTP
(C) dIMP
7 Considering the patient in the previous question, after (D) dGTP
uridine treatment the crystals were no longer found in (E) dUTP
the urine. This is due to which of the following?
(A) Inhibition of the enzyme producing the crystalline
molecule 12 Individuals with gout are given allopurinol for long-term
(B) Bypassing the mutated step of the pathway management of the disease. In such individuals, which
(C) Inhibition of aspartate transcarbamoylase of the following bases would accumulate in the urine?
(D) Inhibition of nitrogen fixation by carbamoyl phos- (A) Urate and xanthine
phate synthetase I (B) Guanine and adenine
(E) Inhibition of carbamoyl phosphate synthetase II (C) Hypoxanthine and guanine
(D) Xanthine and guanine
8 Considering the patient in the last two problems, the (E) Hypoxanthine and xanthine
observed megaloblastic anemia results from which of
the following?
13 A 1-year-old boy was brought to the pediatrician due to
(A) Interference with folate metabolism a developmental delay, biting of his lips and fingers, and
(B) Interference with B12 absorption the presence of orange crystals in his diapers. Enzymatic
(C) Inhibition of ribonucleotide reductase analysis shows loss of 99% of the activity of a particular
(D) Lack of thymidine for DNA synthesis enzyme. The defective enzyme in this disorder would
(E) Lack of adenine for DNA synthesis normally utilize which of the following as a substrate?

Chap18.indd 159 8/26/2009 4:32:35 PM

 160 Chapter 18

(A) Adenine 18 A penicillin-allergic child was given a sulfonamide for

(B) Guanine otitis media. Human cells are resistant to sulfonamides
(C) Adenosine due to which of the following?
(D) Guanosine (A) Sulfonamides are specific for prokaryotic DNA
(E) GMP polymerases
(B) Sulfonamides are specific for prokaryotic RNA
14 Considering the patient in the previous question, the polymerases
orange sand in the diapers was composed of which of (C) Sulfonamides inhibit a metabolic pathway not
the following? present in eukaryotic cells
(A) Xanthine (D) Sulfonamides inhibit bacterial ribonucleotide
(B) Hypoxanthine reductase, but not eukaryotic ribonucleotide
(C) Guanine reductase
(D) Adenine (E) Sulfonamides inhibit prokaryotic mismatch repair,
(E) Urate but not eukaryotic mismatch repair

15 A 6-month-old boy was brought to the pediatrician due to 19 The primary route of carbon entry into the tetrahydro-
frequent bacterial and viral infections. Blood work shows folate (THF) pool is via the serine hydroxymethyl trans-
the complete absence of B and T cells. Radiographic anal- ferase reaction. Which of the following is required to
ysis shows a greatly reduced thymic shadow. Treatment of convert that initial form of the THF into the form that
the child with a stabilized protein reverses the deficien- can donate carbons to de novo purine synthesis?
cies. This protein has which of the following activities? (A) Glycine
(A) Converts IMP to XMP (B) FAD
(B) Converts adenine to AMP (C) Water
(C) Converts guanine to GMP (D) B12
(D) Converts adenosine to inosine (E) B6
(E) Converts guanosine to inosine
20 Many anticancer drugs are given to patients in their
16 Concerning the patient in the previous questions, which nucleoside form, rather than the nucleotide form.
metabolite will accumulate in the blood cells? Which enzyme below will be required in the conversion
(A) dUTP of deoxyguanosine to dGTP?
(B) dCTP (A) Pyrimidine nucleoside phosphorylase
(C) dATP (B) Deoxyguanosine kinase
(D) dGTP (C) Ribonucleotide reductase
(E) dTTP (D) Adenine phosphoribosyltransferase
(E) 5′-nucleotidase
17 Concerning the patient discussed in the last two ques-
tions, one possible reason for the lack of immune cells
is inhibition of which of the following enzymes?
(A) ADA
(B) Purine nucleoside phosphorylase
(C) Hypoxanthine guanine phosphoribosyltransferase
(D) Adenine phosphoribosyltransferase
(E) Ribonucleotide reductase

Chap18.indd 160 8/26/2009 4:32:35 PM

 Purine and Pyrimidine Metabolism 161

ANSWERS and a functional folate deficiency results (see the figure

below). The folate deficiency then results in a macrocytic
1 The answer is A: Adenine. This person has gout. Gout anemia due to the lack of DNA synthesis. Red cell precur-
is caused by uric acid crystallization into a joint and an sors increase in mass but cannot divide due to the lack
intense inflammatory reaction to those crystals. The X-ray of precursors for DNA replication. As a result, larger than
demonstrated soft-tissue swelling over the first metatar- normal cells are released into the circulation, although the
sophalangeal joint and typical gouty erosion. Uric acid overall red cell number decreases, resulting in an anemia.
is an insoluble breakdown product of purines (adenine, Both thalassemia and spherocytosis lead to microcytic
hypoxanthine, or guanine). Pyrimidines (thymine, ura- anemia. Vitamin B12 levels would not be affected, and the
cil, and cytosine) breakdown to different water-soluble normal occult blood tests and colonoscopy indicate that
products that do not crystallize. Ribose-5-phosphate is there is no bleeding leading to the anemia.
also degraded to very water-soluble products. The path-
way of uric acid formation is shown below.

Pteridine ring PABA Glutamate

O
AMP –
HN N OH O COO
H N H H
+ N 5 9 N C N C H
NH4 6
CH2 10
H2N N N 7
8 CH2
RP H2N N N
GMP IMP CH2
Folate
Pi Pi COO–
(F) n

NADPH
Guanosine Inosine
Pi Pi dihydrofolate reductase

Ribose-1- Ribose-1- NADP+

OH
O phosphate O phosphate N H –
N 5 9 N R
N N 6
HN HN CH2 10
7
H H 8 H Methotrexate
H2N N N H
H 2N N N N N H
H H
Dihydrofolate –
Guanine Hypoxanthine
(FH2) NADPH
O2 dihydrofolate reductase
Allopurinol
+ Xanthine oxidase NADP+
NH4
O H2O2 OH H
N N H H
HN N 5 9 N R
6
H CH2 10
8 7 H
O N N H2N N N H
H H
H
Xanthine
Tetrahydrofolate
O2 (FH4)
Allopurinol Xanthine oxidase
H2O2
O
HN N pKa = 5.4 3 The answer is E: Aspartate, glycine, and glutamine. As
–
O shown in the figure below, the nitrogen in a purine ring
O N N is directly derived from glycine, glutamine, and aspartic
H H
acid. Glutamate, N5-formimino tetrahydrofolate, and
Uric acid Urine
asparagine do not directly donate nitrogen to the ring.

The degradative pathway for purines. Note how allopurinol, a drug

CO2 Glycine
used to treat gout, inhibits the enzyme xanthine oxidase, which
reduces uric acid production. Aspartate 6 N
(N) N1 5 7
N10-formyl-
8
2 3 4 9
N FH4
2 The answer is A: A macrocytic anemia. Methotrexate N10-formyl- N Glutamine
acts by inhibiting dihydrofolate reductase such that THF FH4 RP (amide N)
Glutamine
cannot be formed (either from folate or dihydrofolate), (amide N)

Chap18.indd 161 8/26/2009 4:32:35 PM

 162 Chapter 18

4 The answer is B: Thymidylate synthase. 5-fluorouracil is a 6 The answer is C: Orotate. The child has hereditary
thymine analog (thymine is 5-methyl uracil), which, after orotic aciduria, a mutation in the UMP synthase that
activation in the cells to F-dUMP, binds tightly to thymi- leads to orotic acid accumulation in the urine (see the
dylate synthase and blocks the enzyme from converting figure below). Treatment with uridine bypasses the
dUMP to dTMP (see the figure below). By blocking thy- block and allows UTP, CTP, and dTTP synthesis. Uri-
midine synthesis, cells can no longer synthesize DNA and dine treatment also has the beneficial effect of blocking
will not replicate. 5-FU has no direct effect on dihydro-
folate reductase, amidophosphoribosyl transferase, PRPP –
O O
synthase, or UMP synthase. The figure also indicates the C
CH2
effect of methotrexate on dihydrofolate reductase.
CH
+H N
3 COO–

O Aspartate
F H2N
HN
C
O
O N O P
Carbamoyl Pi
H
phosphate
5-Fluorouracil
–
5-Fluorouracil O O
O O C
CH3 H2N CH2
HN thymidylate synthase HN
C CH –
O N O N O N COO
N 5,N 10- H
Deoxyribose-P Methylene FH4 Deoxyribose-P
Carbamoyl
dUMP dTMP
FH2 aspartate
Dihydrofolate
Methotrexate
Glycine
NADPH O
dihydrofolate reductase
FH4 HN
Serine
NADP+
O N COO–
H

5 The answer is A: PRPP. The patient has von Gierke Orotic acid
disease, a lack of glucose-6-phosphatase activity. When (orotate)
this individual tries to produce glucose for export in Orotate
PRPP
the liver, glucose-6-phosphate accumulates, which phosphoribosyl-
transferase PPi
then goes through either glycolysis (generating lac-
tate) or the HMP shunt pathway, producing excess O
ribose-5-phosphate. The excess ribose-5-phosphate is
converted to PRPP, which then stimulates the amido- HN
phosphoribosyl transferase reaction (the rate-limiting
step of purine production) to produce 5′-phosphoribo- O N COO–
syl 1′-amine. This last reaction occurs because under R-5- P
normal cellular conditions, the concentrations of PRPP OMP
and glutamine are significantly below the Km values for
amidophosphoribosyl transferase. Any cellular pertur- Orotidine 5´-P
decarboxylase
bation that increases PRPP levels, then, will increase CO2
the rate of the reaction, producing purines that are not
O
required by the cell. This leads to degradation of the
excess purines, producing urate and leading to gout. HN 3
4
5
The lactic acidosis associated with von Gierke disease 2 6
1
also blocks the transport of urate from the blood into O N
the urine, which contributes to the elevated uric acid R-5- P
levels seen in these patients. Von Gierke disease does
UMP
not lead to elevated glutamine, ATP, NADH, or dTTP
levels. Block in hereditary orotic aciduria

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 168 Chapter 19

(A) Insulin levels (A) Increased activity of lipoprotein lipase

(B) C-peptide levels (B) Increased activity of pancreatic lipase
(C) Fasting blood glucose levels (C) Substrate-induced activation of hormone-sensitive
(D) Random blood glucose levels lipase
(E) Hemoglobin A1C levels (D) Increased transcription of colipase
(E) Activation of microsomal triglyceride transfer protein
7 Your patient, with a BMI of 36 and a waist circumference
of 44 in., has a fasting blood glucose level of 145 mg/dL. 12 Your patient with metabolic syndrome is in for a
One reason for the elevated blood glucose is which of checkup. His HbA1C is 9.0 and his fasting triglycerides
the following? are 325 mg/dL. You prescribe pioglitazone (Actos) to
(A) Enhanced release of glucose from the intestinal epi- better treat his diabetes, but nothing else specific for the
thelial cells high lipids. A month later, the fasting triglyceride levels
(B) Stimulation of GLUT4 transporters in muscle have dropped to 155 mg/dL due to a direct activation of
(C) Activation of pyruvate carboxylase which of the following?
(D) Inhibition of liver GLUT4 transporters (A) AMP-activated protein kinase
(E) Activation of protein kinase B (B) PPAR-γ
(C) Leptin
8 Considering the patient in the previous question, the (D) Adiponectin
primary energy source being used by the muscle is (E) LKB1
which of the following (in the untreated state)?
(A) Glucose 13 Your type 2 diabetic patient has been taking metformin
(B) Amino acids for the past 6 months and has reduced fasting blood
(C) Lactate glucose levels from 185 to 112 mg/dL. This occurs due
to which of the following effects of metformin?
(D) Glycerol
(A) Activation of adenylate cyclase
(E) Fatty acids
(B) Inhibition of the electron transfer chain
9 Considering the patient described in the last two ques- (C) Activation of LKB1
tions, it is likely that your patient is now leptin resistant. (D) Stimulation of amidophosphoribosyl transferase
This has occurred due to which of the following? (E) Stimulation of adenylate kinase
(A) Activation of SMAD4
(B) Downregulation of the leptin receptor 14 The major, defining difference between a type 1 diabetic
(C) Activation of the insulin receptor and a type 2 diabetic is which of the following?
(D) Activation of SOCS3 (A) Weight
(E) Downregulation of anorexigenic factors (B) Ability to produce insulin
(C) LDL levels
10 Sequelae of insulin resistance in type 2 diabetes mel- (D) Blood glucose levels
litus and metabolic syndrome is reduced secretion (E) Serum triglyceride levels
of insulin in response to increases in blood glucose.
Insulin release from the pancreas appears to be depen- 15 Your type 1 diabetic patient was managing their disease
dent upon increase in concentration of which pair of using a combination of Humulin R and Humalog. The
metabolites? Humalog is more rapid acting than the Humulin R due
(A) ATP and CO2 to which of the following?
(B) ATP and NADH (A) Humalog is taken orally, rather than subcutaneously
(C) ATP and NADPH (B) Humulin R is complexed with zinc, which slows its
(D) Glucose-6-phosphate and CO2 absorption
(E) Glucose-6-phosphate and NADH (C) Humalog is complexed with manganese, which
accelerates its absorption
11 An increase in serum free fatty acid levels, as evident in (D) Humulin R is taken orally, which slows its absorption
individuals exhibiting metabolic syndrome, occurs due (E) Humalog is taken through an insulin pump
to which of the following? mechanism

Chap19.indd 168 8/26/2009 4:33:10 PM