Hyperphenylalaninemia (HPA) is a condition caused by
tetrahydrobiopterin (BH4) and
phenylalanine hydroxylase (PAH) deficiencies. It is essential that differential diagnosis be conducted to distinguish these two causes of HPA, because
BH4 deficiency is a more severe disease involving progressive neurologic deterioration. Based on the
biological findings, HPA is defined as a plasma
phenylalanine level of >2.0 mg/dl (>120 μmol/l). The National Biochemistry Reference Laboratory at the Pasteur Institute of Iran initiated
BH4 deficiency screening tests for the first time during the implementation of a nationwide
phenylketonuria (PKU) screening program. Measurement of blood
phenylalanine and urinary
neopterin and
biopterin was conducted by high-performance liquid chromatography in 617 patients with HPA.
Dihydropteridine reductase (DHPR) activity was measured in all patients by kinetic spectrophotometry. Differential diagnosis was conducted for PKU, transient HPA, and BH4 deficiencies.Our results indicated that out of 76 cases involving BH4 deficiencies, 37 had
6-pyruvoyl-tetrahydropterin synthase (
PTPS) deficiency, 35 had
DHPR deficiency, 1 case had
pterin-4a-carbinolamine dehydratase (PCD) deficiency, and 3 cases had
GTP cyclohydrolase I (
GTPCH) deficiency. In this study, 1 novel deletion mutation and 18 novel missense mutations were reported in addition to mutations that had previously been identified and registered in BIOMDB. At present, the screening program for PKU in Iran includes tests that detect different forms of
BH4 deficiency presenting with HPA. Newborns that are BH4-deficient benefit from the availability of the tests because they can receive necessary care before being clinically affected.