A novel mutation in the biliverdin reductase-A gene combined with liver cirrhosis results in hyperbiliverdinaemia (green jaundice).
BACKGROUND
Hyperbiliverdinaemia is a poorly defined clinical sign that has been infrequently reported in cases of liver cirrhosis or liver carcinoma, usually indicating a poor long-term prognosis.


OBJECTIVE
To clarify the pathogenesis of hyperbiliverdinaemia in an extended case report.


METHODS
A 64-year-old man with alcoholic cirrhosis was admitted to hospital with severe bleeding from oesophageal varices. Ultrasonography showed ascites, but no dilatation of the biliary tree. The skin, sclerae, plasma, urine and ascites of the patient showed a greenish appearance. Bilirubin levels were normal, and there were no signs of haemolysis. Biliverdin was analysed in plasma and urine with liquid chromatography coupled to mass spectrometry. The seven exonic regions of the biliverdin reductase-A (BVR-A) gene was amplified by polymerase chain reaction and sequenced.


RESULTS
Biliverdin was present in plasma and urine. In nucleotide 52 of exon I of the DNA isolated from the hyperbiliverdinaemic patient, we discovered a novel heterozygous C-->T nonsense mutation converting an arginine (CGA) in position 18 into a stop codon (TGA) (R18Stop) predicted to truncate the protein N-terminally to the active site Tyr97. Two children of the proband were heterozygous for the identical mutation in the BVR-A gene, but had no clinical signs of liver disease and had normal levels of biliverdin. The BVR-A gene mutation was not found in 200 healthy volunteers or nine patients with end-stage liver cirrhosis.


CONCLUSIONS
Hyperbiliverdinaemia (green jaundice) with green plasma and urine may be caused by a genetic defect in the BVR-A gene in conjunction with decompensated liver cirrhosis.
Gåfvels
Mats
M
Division of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden.
Holmström
Petra
P
Somell
Anna
A
Sjövall
Fredrik
F
Svensson
Jan-Olof
JO
Ståhle
Lars
L
Broomé
Ulrika
U
Stål
Per
P
D001483:Base Sequence; D001664:Biliverdine / Q000097:blood / Q000378:metabolism* / Q000652:urine; D018389:Codon, Nonsense; D018388:Codon, Terminator; D004252:DNA Mutational Analysis; D005091:Exons; D006579:Heterozygote; D006801:Humans; D007565:Jaundice / Q000209:etiology* / Q000235:genetics / Q000378:metabolism; D008104:Liver Cirrhosis, Alcoholic / Q000150:complications* / Q000378:metabolism; D008297:Male; D008875:Middle Aged; D008969:Molecular Sequence Data; D044925:Oxidoreductases Acting on CH-CH Group Donors / Q000235:genetics*; D010375:Pedigree; D012307:Risk Factors; D015854:Up-Regulation
D018389:Codon, Nonsense; D018388:Codon, Terminator; D044925:Oxidoreductases Acting on CH-CH Group Donors; C019789:biliverdin reductase; D001664:Biliverdine