Chapter 7. A Day at the Beach

Introduction Part 1

Lehninger Principles of Biochemistry
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A Day at the Beach

By Cathleen Erin McGreal Michigan State University

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Instructor's Notes

Topic Pre-requisites: Students should have exposure to the topics of Chapters 14–18 and ideally Sections 23.2 and 23.3 of Lehninger, 6th ed.

Overview

This capstone-type case is designed to help students understand the importance of gluconeogenic substrates in human metabolism and the interconnections between carbohydrate, fat, and protein metabolism in humans. Because the focus of this case is the integration of metabolic pathways, we recommend that students be exposed to the topics of Chapters 14–18 and ideally Sections 23.2 and 23.3 of the textbook (Lehninger POB,6th ed.) before beginning this case. These latter two sections could be assigned as preliminary reading before initiating the case if they have not been explicitly covered in the class; in that case, we recommend allowing students additional time to complete this case study.

Students may work individually or in groups to complete this case study. Students are constantly encouraged to refer to their textbook throughout the case, and internet access is permitted, although it is not necessary for the completion of the case. Students are required to iteratively acquire, analyze, and integrate data as they progress through the case and answer assessment questions found throughout the case. All assessment questions are automatically scored.

For this case, students will need to explore all investigative options to complete the case, and so, unlike some other cases in this collection, the number of investigations that students make use of will not be reported.

Learning Objectives

This case is intended for remediating or extending student capabilities in these difficult topics:

  1. Real-world applications of the study of human metabolism. Students will:
    • utilize real biochemical tests to evaluate and “solve” a metabolic disorder case.
    • consider the importance of factors like personal and family history, diet, medications taken, and symptoms in solving a biochemical case.
  2. Critical and interrelated pathways in human central metabolism. Students will:
    • review carbohydrate, lipid, and amino acid metabolic pathways.
    • review fatty acid metabolism and recognize the distinctions between the oxidation of even- and odd-chain fatty acids.
  3. Connections between carbohydrate, fat, and protein metabolism in humans. Students should be able to:
    • outline and explain the importance of gluconeogenic substrates in human metabolism.
      • understand why the inability to convert acetyl-CoA to gluconeogenic substrates in humans leads to protein wasting.
      • explain the importance of ketone body formation and ammonia transport/disposal in human metabolism.
    • explain the important differences between the metabolic intermediates produced by the oxidation of even vs. odd-chain fatty acids.
  4. Practice critical thinking skills involving data. Students will:
    • evaluate data provided by metabolite and enzyme tests.
    • integrate multiple pieces of biochemical data.

Some questions are designed to address areas of difficulty for students

  • Students are often confused about the necessity to maintain glucose homeostasis, even in the presence of circulating ketone bodies… that is, the concept that glucose must always be exported from the liver under all circumstances in the fasted state is not clear to most students.
  • The significance of a fundamental disconnect in human metabolism--the absence of a metabolic pathway to convert acetyl-CoA ultimately to glucose--is often underappreciated or missed entirely by some students.
  • The role of protein wasting as a necessary, but unfortunate consequence of the need for gluconeogenic precursors in the absence of dietary carbohydrates or stored glycogen. It is both a critical aspect of human metabolism and a relevant real-world connection given the rise of protein-heavy diets in Western society (Atkins, etc.).
  • Author note: A common error is to jump immediately into testing a “pet” hypothesis by conducting laboratory tests (metabolite assays or enzyme assays) before exploring “data gathering” options like visual inspections or interviews with the person. This is an excellent and intentionally designed opportunity to point out a common mistake about the scientific method-- that is, it begins with making careful observations, rather than by immediately testing quickly formed hypotheses.

Suggested implementation

Below we describe two options for course implementation. The hybrid Online/In-class approach is recommended. Time required for students to complete the online case will vary by group depending on their level of discussion between each investigation. The case study can be started and stopped, and so it is recommended to give students a window of 3 to 5 days in which to complete the assignment.

Hybrid: Online/In-class: (recommended approach; ~30 minutes of class-time expected)

  1. Share the case study link with your students to work online outside of class, preferably in pairs or groups of three. Assign the case study to be due before your next class meeting. Students should be instructed to bring copies of notes and answers to assessment questions to the following class period.
  2. Review the online answers before the following class for difficult areas for students (see expected areas of difficulty above).
  3. Lead students in a discussion in pairs, groups, or as a class (depending upon class size and instructor preference) to address unresolved difficulties (~30 minutes in-class time).
  4. After using the case, we recommend that you select questions from the supplied assessment questions to use on exams or as homework assignments to reinforce the difficult concepts covered. Please see the document “Exam Questions for Case 4: Integration of Metabolism.”

Online only approach: (minimal in-class time required)

  1. Share the case study link with your students to work online, preferably in pairs or groups of three. Assign the case study to be due before your next class meeting.
  2. Review the online answers for difficult areas for students (see expected areas of difficulty above).
  3. Mention or remediate tough points during a portion of lecture.
  4. After using the case, we recommend that you select questions from the supplied assessment questions to use on exams or as homework assignments to reinforce the difficult concepts covered. Please see the document “Exam Questions for Case 4: Integration of Metabolism.”

Suggestions for in-class discussions (these questions may also be used in summative assessments-- i.e., exams, scored quizzes, etc.):

  • What were some of the most important facts in the initial presentation of Dave and Michael’s case and why were they important?
    • Students could be directed to brainstorm in groups or as a whole class.
  • What were some of the most important facts of Dave and Michael’s case that were revealed as a result of your investigations and why were they important?
    • Students could be directed to brainstorm in groups or as a whole class.
  • What are some issues associated with someone trying to do a diet that is completely based on one type of macronutrient, like fat in this case, or for example a diet entirely of protein?
    • Could be easily used as a think-pair-share exercise.
    • Alternatively, students could first answer this question in writing individually, and then those responses could be collected or discussed in groups and revised.
  • What was the relevance of the brothers being identical twins with respect to this case and to biochemistry in general--i.e., what might we have been concerned about if the brothers were not twins?
  • What is the significance of the two oils the brothers were eating?
  • What was the significance of Michael’s neurological issues?
  • Why did Michael have lower levels of immunoglobins and higher levels of ketone bodies than Dave?
  • Why are high levels of ketone bodies dangerous?

You are missing vital information

You may be missing vital information needed to sufficiently explain this incident. You must complete all investigations before proceeding to the final assessment questions.

You are missing vital information

You may be missing vital information needed to sufficiently explain this incident. You must complete all investigations before proceeding to the final assessment questions.

This activity has already been completed, however feel free to review the information contained within.

You are about to leave the investigation and proceed to the final assessment. Are you sure you wish you to proceed?

Figure 7.1

Jessie knew she was late for the family reunion, probably too late for the big picnic lunch at Forest Lake Beach, but too early for the barbecue dinner. “Too bad” she thought, because she had skipped breakfast as well, trying to get out of the city and on the road to the lake. Perhaps there would be some leftovers; she hoped so, because she was beginning to get that slightly dizzy feeling that meant she was pushing her limits.

No leftovers, but the whole extended family was there: sitting and talking on the beach, playing Frisbee golf, and throwing a football. Some of the younger cousins were having swimming contests out from the floating platform at the edge of the swimming area. Jessie watched the kids swimming, and smiled sadly. She had been a competitive swimmer as a teenager and still missed it. As she watched the group of splashing children, Jessie began to think that something wasn’t right about a little boy off to the right of all the others. She put her hand up to shade her eyes from the sun and squinted; the kid was in trouble! He was throwing his arms around randomly, and thrashing the water into froth. None of the other children were close enough to notice, and there didn’t seem to be any other adults near enough to raise the alarm.

7.1 Introduction Part 2

Figure 7.2

Without any further thought, Jessie ran into the lake, and after the first few lunges through the water, dove shallowly and began swimming towards the now sinking child. Her muscle memory kicked in and her strokes became fast, efficient, and powerful. With each stroke she raised her head enough to keep the small head in sight; she was making progress, but he was going down! She pushed harder, picked up speed, and then she saw him, underwater, sinking quickly despite his frenzied paddling. Jessie took a breath and dove; she grabbed the little guy’s surfer swim shorts, and kicked hard back toward the surface. She began the one-sided stroke that allowed her to keep his head above the water, and swam toward the beach, which seemed, strangely, to be disappearing into a haze. Jessie felt exhausted, but kept swimming, breathing in short gasps. Her vision narrowed, and she barely felt the sand under her knees as reached the shallow water. As the little boy was taken from her arms, Jessie lost consciousness.

7.2 Introduction Part 3

Jessie woke up in the hospital emergency room, very weak and confused. She tried to sit up, but her arms and legs felt heavy, completely without strength. She was dizzy, disoriented, and exhausted. A gray-haired woman in a short white coat came into view, as well as a younger person dressed in scrubs.

“Hello, Jessie. Glad to see you’re finally awake. You were out for a pretty long time. I understand you are a hero; saved the day and your little cousin. Can you tell me what happened to make you faint? Did you hit your head, or swallow too much water? Everyone said that you were a really good swimmer, and so no one understood why you fainted.”

Figure 7.3

Jessie took a deep and unsteady breath. “I haven’t tried to swim that hard since I had a head injury, 5 years ago." When the ER doctor asked Jessie if anything like this had happened to before, she looked sheepish and said “yes”. She recalled similar episodes, all under similar circumstances—"pushing herself too hard".

7.3 Gathering Information

You are a biochemistry student who is shadowing the ER doctor. With the assistance of the physician, you may conduct additional investigations to determine the cause of Jessie’s incident. The goal of this exercise is to correctly solve the biochemical case without carrying out completely unnecessary investigations; hence, you are encouraged to carefully consider the information you receive with each investigation and avoid haphazard guessing. You will be scored on this exercise based on your answers to assessment questions found throughout the case so you are STRONGLY encouraged to use your textbook to complete this exercise; you may also use the internet as necessary.

Figure 7.4

Please note that there is a minimum set of investigations that must be conducted in order to have all the necessary information to fully understand the case. The number of investigations you select will be recorded and reported to your instructor, so randomly guessing could adversely affect your score. You should be both thorough and thoughtful in conducting your investigation. Hint: we recommend that you first thoroughly exhaust the use of broader initial investigation options, like interviewing someone, before proceeding to test specific hypotheses by doing more specific tests for particular enzyme activities, for example. After completing these initial investigations, ask yourself, what further investigations or lab tests would you like to conduct based on the information gathered so far? For starters, you might also consider what, metabolically, might make a person lose consciousness…

7.4 Investigation Options

RECOMMENDED INITIAL INVESTIGATIONS

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Evaluate overall physical appearance including the presence of insect bites or other injuries

Results: Subject is a young, adult female with a slim, athletic frame but otherwise appears normal.

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Fecal analysis – Look for blood, intestinal parasites, high levels of fat in stool

Results: No blood or intestinal parasites were found. Levels of fat in the stool were normal considering the subject’s recent food intake.

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Interview patient to determine dietary habits and look for neurological problems

Results: No abnormalities in cognitive function were found. Jessie reported being a strict vegan for many years; however, she claims to get a large amount of protein from plant sources. She also reports eating a high calorie diet and occasional, moderate alcohol consumption. She says that she is a non-smoker, does not use illegal drugs, and does not recall eating anything unusual recently; in fact, she had not eaten anything yet on the day of the fainting episode because she was in a rush. You ask whether she knows whether she might be diabetic or has had any trouble in the past controlling her blood sugar levels and she responds by saying “I really don’t know.”

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Investigate past medical history

Results: Jessie explained that she was on the verge of gaining a swimming scholarship to college when she injured her head in a rock climbing accident. Her head injury led to epileptic episodes that were now controlled by regularly taking anticonvulsant drugs. Swimming was one of the activities she gave up because of the fear of seizures. She reports that, since the accident, she has had less endurance, which she had always ascribed to the fact that she was no longer working out regularly. She sighed and said longingly, “I don’t swim anymore… don’t really do much of anything in terms of hard exercise. I am just miserably out of shape, I guess.” You ask whether she has had a blood test to look at her blood lipid profile recently and she responds that she has not had a full physical since she was dismissed from the hospital five years ago.

SECONDARY INVESTIGATIONS

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Determine Blood Serum Concentrations

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Common electrolytes: Ca2+, K+, Na+, Cl-, PO43-

Results: All values are in normal ranges. (normal ranges: [Ca2+] = 8.5-10.5 gm/dL; [K+] = 3.5-5.0 meq/L; [Na+] = 135-145 meq/L; [Cl-] = 100-106 meq/L; total phosphorus = 2.6 – 4.5 mg/dL)

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Common lipids: free fatty acids (FFAs), triacylglycerides (TAGs), total cholesterol, and ketone bodies (acetoacetate as a marker)

Results: [FFAs] = 500 mg/dL (normal range: 190-420 mg/dL); [TAGs] = 175mg/dL (normal range: 40-150 mg/dL); [Total cholesterol] = 140 mg/dL (normal range: 120-200 mg/dL); acetoacetate was undetectable

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Question 7.1

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
5
Correct.
Try again.
Incorrect.
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Question 7.2

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
5
Correct.
Try again.
Incorrect.
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Question 7.3

Which of the following would you expect to be elevated in the blood of a person who has been fasting for 12 hours, compared to a person who has recently eaten a large meal with carbohydrate, protein, and fat? (Select ALL that apply!)

a. TAGs Fd/yhwSeUQ6ZqQj4
b. Free Fatty Acids (FFAs) uS+xJY+rPntALoOB
c. Ketone bodies uS+xJY+rPntALoOB
e. Glucose Fd/yhwSeUQ6ZqQj4
f. Insulin Fd/yhwSeUQ6ZqQj4
g. Glucagon uS+xJY+rPntALoOB
Table : Table Caption
5
Correct.
Incorrect. You should have selected three answer options as true.
Incorrect.
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true

Question 7.4

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
5
Correct. The discovery that Jessie has elevated levels of TAGs and FFAs, but no ketone bodies has opened up a new investigation option! All of the blood-level data comes from just a single moment in time… it might be more informative to see how Jessie’s lipid levels respond to fasting.
Try again.
Incorrect.
6
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Glucose

Results: [Glc] = 60 mg/dL (normal range: 70-110 mg/dL)

inv14

Question 7.5

Lzc8RjcGBhy5uQtC0mW2WvZVtm4OGWOxvdnTE3YBpd+JZZpbgDekdrClJGYuwY7SdyQS4tSXhUpq8qNsu7RPMUtD9U5+OXs5BSX7WA9NXp0K0Dkv0EWEyLviDbnTVLYCMpS+vHU/uNY3FKobiD14hLAO5zodzqz7oDIH8AZxGuz1a0iel2xr69r7MdK2QZ4J1nS+94JklQETHyPAPtKQusMRsLSq3GvhtslTLOij8bHU3MuuShXxSi1x2ag0qe4sAZMpLxIZI1sSOgoNHyPNX80JmngP8zSQvWxRoJqThy7D8huDBXkgAOYuaFgiMaM1+w0vnPyzggwrhYdzzGPLChyrL3pCwQGyxX9F9F8BQIOa9vF4/OKSdMFkeTeOG/2fJnfozveKa7PeADuEYSI18X3ztFzF1ahtDQhDYvTJMD2ck26FMHwKL/z+9ETBQjtut9I2RxltYl4c1oIVURhbZXBNvcxPrTN+34u7WjlD3jBaF31jyrab3V8QGu4YUZBBmmK9PRI+SZx+r0/6Ac3TUQ5hYrApS8bG5JEeSZ01UHL2htIDT3bjYXYsPcG+nA50ZWLkHt3aiqC1AJM1scEVDUQsvWHwGy6TJRTMC1FdRkcJQrELlUiRxBT5seTmDXsp9XJhsGCVentjGpoSRWlI28eByK/8wHQ9FWRzArmklCrXr9KM3ZY0ww4Jkp0o4cZUlIuQ0Zx+A7wleuRoi/sHXt1mAGFYWtKGZ0rKckrwD4ozPUxGmekLEUsOKc2WxlU+C8SunqKslMQQgmXBL/0M9b1Fm5Hp/raO9fZCdvLh2hn84VUG9YNrGga8oCox2VpKM2bT5+YKTZmq6QGt9AJy7wxg0pylssFwiWmbAk+raxb2eubU+rZBZZ5cNuQCyl88rGrzd9LyDf/WAHbfWzjke5EJaZfJ3tTloo3occVB+vH+bymqUvKEx6w4A/xWJreH9W8KUn/vUWJFpKtzQySh7PVmg4Q6Sgs5velJ9Q5siv5t2j73zXho/DEaPHAtMYrLG+8xRBOkBTNc2XNc6rcbfj+Yi89OfWKYd7Da+6zjipEOPKcjXDRpEGRItu6S/UiIcGS6YFU5DuNvO1W3k119bwKyIg5kTdZQCrvOKS4Utof2+YRV1sEZlqsmKUXCxx5M7aEJI5W3a1bhuPi+quSVH1c+RNg32NV9rodW8sn8azbxIz9TEN/LNbNkdmF9/PeDuR1SlECMMjx8l88IdXOHDVIDL+sN4GVXT9e6R+KrFtr7Owuu5QgglUkfEayWqzOnVYf/kS51sg0PBtI1MUNheEFHZVqBpkBHzsyTeXYbBRVOxuDaD6meYx8EkPxLMyPP+ioG4pqa9GciiXji7Y/CO5AxnlChUHTsPursovaY4ijFMOdX8lg3b5ZN+7PK5afezJQwJWL7rLPzRqhqh77Jty+0JKguq9QBp7vd1NH9mdr8OkZfllPMFOUC4lH4uspVvnWUSvD9Y3UJWGOY+abGpwALTj0MvXcfccoaz5ReAbCjZ0PAZBEQKWjMg6I9/boPWCCWr7C0KVaaLkIh+HcF1DsltlrXg4+xsTY+dAtW/dS2jl5Kb3Bk6S2+EehGK3rwcI0N2UZDbXgS6O+Cy+C9vKlgk9AtgEYOIldsNdRKdapvPSBRrSALdIRdLx1Dq3yDEe9JeQOpL0oQ+F255aaReNl7LYdCmcFP1niN5bdVqlXsVsZB/8ZKpY6VmaO66nW5Z3bEQ9c7UlMSjFSYd9OdRqD4I6wlh6uFS8wLiYLIMRX4GbSd3UDEJ4m4jQvIbfUDP5F3/yPX4vzghwZY3upSpF0yH653Zs3FF2eW3N38UFasFCwcG1cuYiv1ajofl8/70hRgEPMqziAEctjg1eUqF8mmycioL6UZ3A0IDxCwDX5zAKjRXx3oYThQFaknDmGs/kgZWfOHJ8RPZBxxqRSEgkHuJCttC4SmY8i68/3wMsiI4IT1ZaXsFkfZl+NlSk70D9g1tBbYkAPEjJCOgYfsbHgbHpo8jgIizO3e1ASuT0fd/+wSB4XSvDEzE77ULohimUFaH06jsimlObtvzV1o4VqfzCjPEmLQg+7kLQh2gpPvWa7Ex0yA6K0hmlJzJt2Q5xBlZOYxry0cw1sSLJ20Ieq/g+j5kIRdpEoTy8DRcN+ZS+ZVinvwtBASQ7bgxmqBGH1cV8Ey4K4GWyMgcNJWB3S8Q4z/mKvNLm7+3AsOP6JlaJ6KWim56FiL7BW1KZxRvcD1jEqejEMpsZhtp156DYiIPXHuP0o9Tk9PhsCpjSIqIYflYm0clVhGDN0siaNLAE2dxfPyNVr4Mp/5yG/sQFXlWV4jCO54DgUBprHZzKtfXTx1IXak2rnm3pZFkEsfoK9z3UhqQMiZppci7YZ+h4RRRpF0/cefmkLyRuxkX8qQbNKJRl4cv3hw/KK44UUPAr2Jl+mSGP6O84tAHAS9jUrynYff/UDiBBVELTNGCKQBlN8Kfmll9IfPkF7MIlFA7lnuZFDFqo+DPzfKWUyZUWSeD9XBsXdf/jFxcbEjVoKY/Z7aCq6rmPV8ezcB+yb28ki9MLKvXkJQpFQU8Lx78qggpK9fB/z5IEw0kH4Nnij9exasfnc6i8NJN+xHT3phBrX4mekRzKz6Uo6FzIbSv4s/+Or4vEHAky0b7VebFnlUCFi2sDXFrZg4S5qQwt8Quo5E2dhVyw+3ZPnFSFkceJd2GL51Kx+89HhBia457ByFSLvvmqz9OzH5u9acazPLLPkp8PVh8uXHzv6dn5B12z52lXb0rxz1fF253HzIQpmQH5X8lzSyluAcesEjWt9pRegw0Z1ho7Q+0Ymcq/Qr8UCN5K+O6yDlu2CVA0BrUKfUL7eWLdpSfBm011XN1HOKbLwt/bn5+5UEqzJtv9xYXMNS/Z3zKOp9w0uyvmgntfXkdMT05MWKQSDYRjigEG3Hx+dVk+vnGnLSKob3CB48gdBmMkzZkV55fcUyV60Uig3majcvP8ffRGLSoetMIgxdy5OY6T2EYIuCwxu7atwDvG0S/k2YyWHIm8Bsxoy3kQ7XMg+AiPNXkPVRpHzYOOvLuhWhBJdgQtblan52xBWXntlVpuaiO2KofRaM7A==
6
Correct.
Try again.
Incorrect.
inv15
true

Question 7.6

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
6
Correct. The discovery that Jessie is hypoglycemic has opened up a new investigation option! The new option is: Measure blood levels of glycated Hb (HbA1c as a marker)
Try again.
Incorrect.
1

H3O+ ions: blood pH

Results: pH = 7.41 (normal range: 7.35 – 7.45)

Lactate and pyruvate

Results: [lactate] = 1.0 meq/L (normal range: 0.5-2.2 meq/L); [pyruvate] = 0.05 meq/L (normal range: 0 – 0.11 meq/L)

NH4+ (total ammonia)

Results: [NH4+] = 45 mmol/L (normal range: 12-48mmol/L)

O2 and CO2

Results: PO2 = 88 mmHg (normal range: 75-100mmHg); PCO2 = 41 mmHg (normal range: 35-45 mmHg)

Total protein (mostly albumin)

Results: [total protein] = 4.9 g/dL (normal range: 6.0-8.0 g/dL)

true

Specific enzyme tests

inv5

Asp amino-transaminases (AST) and Ala amino-transferase (ALT)

Results: Both enzymes are within normal range (normal range: 7-55 U/L)

inv6

Aldolase

Results: [Aldolase] = 1.0 U/mL (normal range: 0-7 U/mL)

inv6
true

Carnitine acyltransferases I & II (CAT I & CAT II)

Results: The activity of both transporters was found to be well below normal. Expression levels of both proteins were actually slightly elevated, however.

inv13

Test cells for Electron Transport Chain enzyme activities

Results: ETC enzyme activities were normal

Creatine kinase (CK)

Results: CK] = 100 U/L (normal range: 40-150 U/L)

Glucose 6-phosphate dehydrogenase (G6PD)

Results: [G6PD] = 8 U/g Hb (normal range: 5-13 U/g Hb)

Lactate dehydrogenase (LDH)

Results: [LDH] = 150 U/L (normal range: 110-210 U/L)

Pyruvate dehydrogenase (PDH)

Results: PDH complex activity= 2.5 nmol/min*mg (normal range: 2-2.5 nmol/min*mg)

true
1

Measure blood levels of glycated Hb (HbA 1c as a marker)

Results: HbA1c = 3.2 % (normal range: 4 - 6.5%)

inv19

Question 7.7

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3
Correct.
Try again.
Incorrect.
inv19
true

Question 7.8

Which of the following factors can affect the concentration of glucose in the blood? (Select ALL that apply!)

a. Ability to release insulin uS+xJY+rPntALoOB
b. Ability to respond to insulin (insulin sensitivity) uS+xJY+rPntALoOB
c. Ability to release and respond to glucagon uS+xJY+rPntALoOB
d. The availability of glycogen in the liver uS+xJY+rPntALoOB
e. The availability of gluconeogenic (also called glucogenic) substrates to fuel gluconeogenesis and glucose export in the liver uS+xJY+rPntALoOB
f. The ability of the liver to produce ketone bodies when necessary uS+xJY+rPntALoOB
Table
3
Correct. The discovery that Jessie has chronic, not just temporary, hypoglycemia indicates that she might have some problems with hormonal regulation of glucose metabolism (and/or another problem). To test the hypothesis that her hypoglycemia is due to a hormonal issue, you could have her take a glucose tolerance test and examine how her body responds to glucose in her diet. In this test, a person fasts and then swallows a solution of glucose. Changes in blood glucose as well as insulin and glucagon are followed over time. The following is now a new investigation that you may conduct: Conduct an oral glucose tolerance test to measure changes in insulin, glucagon, and blood glucose when oral glucose is administered.
Incorrect. You should have selected six answer options as true.
Incorrect.
2

inv23
2

Conduct an oral glucose tolerance test to measure changes in insulin, glucagon, and blood glucose when oral glucose is administered.

Results: Jessie fasted for 12 hours prior to the test, and her glucose, glucagon, and insulin levels were measured just before the test began. She was then given 75 grams of glucose in water to drink, and her blood was drawn and tested every 60 minutes for 5 hours. Results were as follows: She was hypoglycemic when the test began but otherwise showed completely normal responses to the glucose challenge (to be explained in greater detail in the following assessment questions!). In the very last hour, her blood glucose slowly decreased to below normal levels (hypoglycemia).

inv19

Question 7.9

When a person has fasted for 12 hours before a test like this, blood glucose is still being used by the brain and other tissues. How is that glucose being replenished? (Select ALL that apply!)

A. Muscles run gluconeogenesis and export glucose into the blood. Fd/yhwSeUQ6ZqQj4
B. Muscles run glycogenolysis and export glucose into the blood. Fd/yhwSeUQ6ZqQj4
C. Large amounts of dietary glucose are still being absorbed from the digestive tract. Fd/yhwSeUQ6ZqQj4
D. The liver runs gluconeogenesis and exports glucose into the blood. uS+xJY+rPntALoOB
E. The liver runs glycogenolysis and exports glucose into the blood uS+xJY+rPntALoOB
F. The brain makes its own glucose from large amounts of glycogen stored in the brain. Fd/yhwSeUQ6ZqQj4
G. Adipocytes breakdown TAGs to fatty acids and then convert those fatty acids to glucose, which is then exported by the adipocyte Fd/yhwSeUQ6ZqQj4
Table
6
Correct.
Incorrect. You should have selected two answer options as true. When the liver exports glucose into the blood, consider the possible sources for this glucose. Review the sources of blood glucose discussed in sections 14.4 and 15.4 of Lehninger 6E and please try again.
Incorrect.
inv19

Question 7.10

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
4
Correct.
Try again.
Incorrect.
inv19

Question 7.11

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
4
Correct.
Try again.
Incorrect.
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Question 7.12

What is happening in a healthy individual about an hour into a glucose tolerance test? (Note: At this early time-point, blood glucose levels are still high. Also, remember that a person who is taking a glucose tolerance test was fasting for 12 hours prior to the test!) (Select ALL that apply!)

A. Glucose is being exported by the liver AD2YBdbb6x3kfgtembjVpQ==
B. Glucose is being taken up by the liver Efx3eLtX1Ia8xzC/fjL6GA==
C. Glucose is being taken up by adipocytes Efx3eLtX1Ia8xzC/fjL6GA==
D. Glycogen is being synthesized by adipocytes AD2YBdbb6x3kfgtembjVpQ==
E. Triacylglycerides are being synthesized by adipocytes Efx3eLtX1Ia8xzC/fjL6GA==
F. Glycogen is being synthesized by the liver Efx3eLtX1Ia8xzC/fjL6GA==
G. Glucose is being taken up by muscle cells that are deficient in glycogen Efx3eLtX1Ia8xzC/fjL6GA==
H. Glycogen is being synthesized by muscle cells where it is needed Efx3eLtX1Ia8xzC/fjL6GA==
I. Glucose is being taken up by the brain Efx3eLtX1Ia8xzC/fjL6GA==
J. Large amounts of glycogen are being synthesized by the brain AD2YBdbb6x3kfgtembjVpQ==
Table
9
Correct.
Incorrect. You should have selected seven answer options as true. Consider all the ways a fasting person’s body might react when blood glucose levels are suddenly increased. Review the details of the glucose tolerance test as described in this case and review the reciprocal effects of insulin and glucagon on glucose metabolism in Chapter 15 of Lehninger 6E and please try again.
Incorrect.
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true

Question 7.13

In a healthy individual, glucose concentrations will spike but then return to normal levels during a glucose tolerance test. In a Type I diabetic, they will spike dramatically, due to a lack of insulin release and remain high. In a Type II diabetic, they will also spike dramatically, but due to a lack of insulin response (reduced sensitivity to insulin) and remain high. Jessie had normal glucose levels throughout the glucose tolerance test except that she was more hypoglycemic than normal at the beginning and the end of the test. Which of the following could explain her test results? (Select ALL that apply!)

A. Jessie is a Type I diabetic AD2YBdbb6x3kfgtembjVpQ==
B. Jessie is a Type II diabetic AD2YBdbb6x3kfgtembjVpQ==
C. Jessie may have a problem with gluconeogenesis in the liver resulting in lower than normal glucose production during fasting Efx3eLtX1Ia8xzC/fjL6GA==
D. Jessie may have a problem with the production of ATP from other sources, i.e., beta-oxidation of fatty acids, which results in increased glucose uptake by tissues from the blood to compensate. Efx3eLtX1Ia8xzC/fjL6GA==
E. Jessie may have glucagon levels that are too high when fasting AD2YBdbb6x3kfgtembjVpQ==
F. Jessie may have glucagon levels that are too low when fasting Efx3eLtX1Ia8xzC/fjL6GA==
Table
5
Correct. Jessie’s hormone levels were also examined during the glucose tolerance test: her insulin and glucagon levels responded normally to the test and returned to normal levels at the end (i.e., her glucagon levels are elevated but not abnormally high, as should be expected when she is fasted, and her insulin levels are low under those same conditions). She obviously has some other issue with the ability to maintain glucose homeostasis. Depending upon the other investigations you have already conducted, you may need to continue to conduct additional investigations to determine what is specifically wrong with Jessie to complete this case.
Incorrect. You should have selected three answer options as true. Review the details of the glucose tolerance test as described in this case, the details of the case, and the sources of blood glucose discussed in sections 14.4 and 15.4 of Lehninger 6E and please try again.
Incorrect.

inv23
6

Conduct a fasting metabolism study to monitor subject’s FFAs and ketone bodies in response to fasting

Results: A 40-hr fasting study was performed. Refer to the figure below to see how Jessie’s blood FFAs, and acetoacetate and γ-hydroxybutyrate levels changed during the fasting study. (Note that at the beginning of the study, she had just eaten!)

<GRAPH IMAGES>

The physician who oversaw the study noted two things that were abnormal compared to a normal person who participates in the same fasting study:

1. Healthy individuals produce significant levels of ketone bodies by the end of the 36-hour fast whereas Jessie produced barely any.

2. The study was abruptly halted after only 36 hours because Jessie fainted again! Fasting for 36 hours is clearly not safe for Jessie! Depending on what other investigations you have already conducted, it may or may not be clear why Jessie would faint during this study but her glucose levels are something that would be important to investigate if you have not already…

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Question 7.14

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
5
Correct.
Try again.
Incorrect.
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Question 7.15

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
5
Correct. The discovery that Jessie has very low levels of ketone body formation and a build-up of free fatty acids could be explained if β-oxidation is somehow blocked, but how it is blocked is unclear. Consider that Jessie did not always have these problems. Consult your textbook to review the reactions and processes necessary to convert palmitate (from a TAG) all the way to acetoacetate (Pages 670-688 of Lehninger 6E).
Review Pages 670-688 of Lehninger 6E
Incorrect.
4

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4

Continue the case

There are multiple possible explanations for how and why beta-oxidation might be blocked. Consider that there could be an inborn error in metabolism (a polymorphism in a gene coding for an enzyme in the pathway), a vitamin deficiency leading to the lack of enzyme action, or a problem with the transport of fatty acids into the mitochondria among other possibilities.

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Question 7.16

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
5
Correct.
Try again.
Incorrect.
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true

Question 7.17

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
5
Correct. The fatty acid chains in TAGs and phospholipids are generally 14 carbons long or longer. Since the majority of dietary lipids come from TAGs and phospholipids of other organisms, short-chain fatty acids are neither prevalent in the human diet (with a few exceptions like coconuts!) nor are they produced by lipolysis of TAGs stored within the body. As such, the lipid metabolism we have studied in Jessie’s body has been primarily long-chain fatty acid metabolism. Because short-chain fatty acids do not require special transport, it might be informative to see how Jessie’s body responds to short-chain fatty acids. You have opened up a new investigation option! The new option is: Investigate short-chain (12 carbons or less) fatty acid metabolism: Monitor ketone body formation in the blood
Try again.
Incorrect.
5

true
inv12
5

Investigate short-chain (12 carbons or less) fatty acid metabolism: Monitor ketone body formation in the bloo

Results: Interestingly, when Jessie was fed a solution containing short-chain fatty acids and again fasted, plasma acetoacetate and γ-hydroxybutyrate concentrations increased.

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Question 7.18

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
4
Correct.
Try again.
Incorrect.
inv19
true

Question 7.19

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
3
Correct. If the hypothesis that ‘long-chain fatty acid transport into the mitochondria is deficient’ is correct, then we might expect Jessie to have unusual fat deposition in the liver. This is common in people suffering from obesity or diabetes, but uncommon in a fit, young person. Excessive fat accumulation in the liver may lead to loss of liver function. You have opened up a new possible investigation! It used to be necessary to actually remove a piece of the liver (biopsy) to measure fat content, which can be dangerous. In the last few years it has become possible to measure liver fat with a Magnetic Resonance Imaging (MRI) scan. The new investigation option is: Conduct an MRI to determine liver fat levels.
Try again.
Incorrect.
7

true
7

Conduct an MRI to determine liver fat levels.

Results: Concentrations of liver fat were found to be 12%. (normal range = 3-5.5%)

inv19

Question 7.20

These results confirm that fat is indeed being deposited in Jessie’s liver, a health hazard that Jessie was completely unaware of! Jessie’s liver fat concentration supports the hypothesis that fatty acid oxidation is impaired. Jessie is very grateful for your help so far. In a previous investigation you also found evidence that the specific problem is likely to be the inability to transport long-chain fatty acids into the mitochondria, since short-chain acids are processed normally. The exact problem and cause still remain to be determined, so you must continue with your investigations. Consider this question before returning to additional investigations: Which of the following proteins are involved in the transport of long-chain fatty acids into the mitochondria? (Select ALL that apply!)

A. Pyruvate dehydrogenase AD2YBdbb6x3kfgtembjVpQ==
B. Carnitine acyltransferase I (CAT I) Efx3eLtX1Ia8xzC/fjL6GA==
C. Citrate synthase AD2YBdbb6x3kfgtembjVpQ==
D. Carnitine acyltransferase II (CAT II) Efx3eLtX1Ia8xzC/fjL6GA==
E. Aldolase AD2YBdbb6x3kfgtembjVpQ==
F. Acyl-CoA dehydrogenase AD2YBdbb6x3kfgtembjVpQ==
Table
Correct. You have uncovered a number of important clues, but depending upon which other investigations you have already conducted, you may need to continue to conduct additional investigations to determine what is specifically wrong with Jessie to complete this case.
Incorrect.

7.5 Follow Up Questions

You have uncovered almost all the information necessary to explain Jessie’s health issues, but something still does not add up: specifically, why is she having these problems now and not all of her life? For example, if she has an inborn error of one of the genes encoding for CAT I or CAT II, you would expect that she would have always suffered from bouts of hypoglycemia. You discuss all the results with the physician you are working with and she suggests that you never actually asked Jessie what medication she was taking for the seizures she was having! It may be nothing, but what an oversight! The following new investigation is now available:

inv83
true

Ask again about past medical history including a list of current medications

Results: She reported, “I take an anticonvulsant drug, valproic acid, to control the seizures. Why, what does that have to do with anything?”

Investigate the physiological side effects of valproic acid

You quickly look up the side effects of valproic acid on your smart phone; it can cause nausea and vomiting, anorexia, carnitine deficiency, and abnormal bleeding, in patients on certain diets. You ask Jessie, and she says that she has experienced none of these—as far as she knows…

The investigation into the potential side effects of valproic acid has opened up seven new investigation options! Review your previous results so far in this case and consider whether this new information provides any logical explanation for Jessie’s odd metabolic limitations. What would you like to investigate next? The new options opened are:

inv12

Ask Jessie to think hard about whether she has been vomiting recently

Result: Jessie restates that she has not had any bouts of nausea or vomiting recently. She is mildly annoyed by this question.

inv12

Ask Jessie to think hard about whether she might have a carnitine deficiency

Result: Jessie responds with a puzzled look and says: “Umm… I don’t think so…but what is carnitine anyway?”. The physician you are shadowing steps in and clarifies that Jessie would not know whether she has a carnitine deficiency or not.

inv12
true

Measure blood levels of carnitine

Result: [Carnitine] = 5 µmol/L (normal range: 24-64 µmol/L)

Jessie has a severe carnitine deficiency! Carnitine is synthesized in humans from the amino acids methionine and lysine, but it is also acquired in the diet. As the name implies, carnitine is especially abundant in meat and dairy products. Because a typical omnivorous diet provides ~75% of a person’s carnitine, carnitine is sometimes considered a vitamin. However, since it can be synthesized de novo means that it is not a true vitamin. Valproic acid depletes carnitine stores in the body by multiple mechanisms but rarely results in true carnitine deficiency in most people. Something to consider: Why is Jessie experiencing carnitine deficiency? Is there any other aspect about her that might make her particularly sensitive to this side-effect of valproic acid?

inv12

Measure blood levels of CoA

Result: Levels of Coenzyme A are normal

inv23

Measure blood levels of valproic acid

Result: Valproic acid and its metabolites are detected in the blood. Levels are normal and appropriate for the dose that Jessie is taking to control her seizures

inv12

Look for abnormal bleeding in the GI tract

Result: You request that Jessie submit to an endoscopy and a colonoscopy. However, the physician you are shadowing disagrees with you - this is not a necessary set of procedures since Jessie does not report any bleeding and does not have any other apparent symptoms that would justify doing these procedures. She also notes that bleeding in the GI tract, even if it is found, does not explain the symptoms that Jessie is exhibiting.

inv12

Send Jessie to a councilor to discuss the possibility that she might be anorexic

Result: Jessie is deeply insulted by the insinuation; she has already stated that she eats a high calorie, but vegan, diet and takes your suggestion as an insinuation that she has been lying to you. She restates that she eats regularly and abundantly.

7.6 Final Assessment

inv23
true

Question 7.21

Which of the following metabolic changes will occur in a typical human after a meal balanced in carbohydrates, protein, and fat is consumed? (Select ALL that apply!)

A. Liver glycogen synthesis increases Efx3eLtX1Ia8xzC/fjL6GA==
B. Muscle glycogenolysis increases AD2YBdbb6x3kfgtembjVpQ==
C. Liver gluconeogenesis decreases Efx3eLtX1Ia8xzC/fjL6GA==
D. Insulin levels in the blood decrease AD2YBdbb6x3kfgtembjVpQ==
E. Ketone body production in the liver is increased AD2YBdbb6x3kfgtembjVpQ==
Table
Correct.
Incorrect. You have not identified all correct answers. Review chapter 15 (pages 587-626) and chapter 17 (pages 667-688) of Lehninger 6E and please try again.
4
inv23
true

Question 7.22

Which of the following metabolic changes will occur in a typical human during 12 hours of fasting? (Select ALL that apply.)

A. Liver glycogen synthesis decreases Efx3eLtX1Ia8xzC/fjL6GA==
B. Liver glycogenolysis decreases AD2YBdbb6x3kfgtembjVpQ==
C. Liver gluconeogenesis increases Efx3eLtX1Ia8xzC/fjL6GA==
D. Liver fatty acid oxidation increases Efx3eLtX1Ia8xzC/fjL6GA==
E. Ketone body formation increases Efx3eLtX1Ia8xzC/fjL6GA==
Table
Correct.
Incorrect. You have not identified all correct answers. Review chapters 16 (pages 633-658) and 17 (pages 667-688) of Lehninger 6E and please try again.
4
inv23
true

Question 7.23

Fatty acids in the bloodstream that are NOT part of TAGs or phospholipids: (Select ALL that apply!)

A. Are present at levels that are independent of epinephrine, glucagon, or insulin levels AD2YBdbb6x3kfgtembjVpQ==
B. Are carried by the protein serum albumin Efx3eLtX1Ia8xzC/fjL6GA==
C. Are soluble in the aqueous phase of the blood in free form AD2YBdbb6x3kfgtembjVpQ==
D. Are nonexistent; the blood only carries ketone bodies AD2YBdbb6x3kfgtembjVpQ==
E. Are carried as part of the lipid bilayer of LDLs and chylomicrons AD2YBdbb6x3kfgtembjVpQ==
F. Originate primarily from stored TAGs in adipose tissue Efx3eLtX1Ia8xzC/fjL6GA==
G. Originate primarily from dietary fats that have just been released into the bloodstream from intestinal endothelial cells AD2YBdbb6x3kfgtembjVpQ==
Table
Correct.
Incorrect. Hint if fewer than all correct answers are selected: You have not identified all correct answers. Review section 17.1 (pages 670-672) of Lehninger 6E and please try again.
6
inv23
true

Question 7.24

Which of the following statements about ketone bodies is/are true? (Select ALL that are true.)

A. One cause of ketone body formation can be that oxaloacetate is scarce due to its use as a gluconeogenic substrate Efx3eLtX1Ia8xzC/fjL6GA==
B. The production of ketone bodies frees up molecules of CoA so that β-oxidation can continue Efx3eLtX1Ia8xzC/fjL6GA==
C. Ketone bodies are produced only during vigorous exercise AD2YBdbb6x3kfgtembjVpQ==
D. Ketone bodies provide an alternate substrate for glycolysis in the brain AD2YBdbb6x3kfgtembjVpQ==
E. Ketone bodies are formed in the brain when β-oxidation is interrupted AD2YBdbb6x3kfgtembjVpQ==
Table
Correct.
Incorrect. You have not identified all correct answers. Review section 17.3 (pages 686-688) of Lehninger 6E and please try again.
4
inv23
true

Question 7.25

Marasmus is the medical term for the condition that results from overall calorie starvation. In developed countries like the U.S., it is relatively uncommon. However, there is a common psychological illness, anorexia nervosa that results in the same symptoms and problems as marasmus. Both conditions result in high ratios of glucagon to insulin. Having a high ratio of glucagon to insulin would do which of the following in most healthy people? (Select ALL that apply!)

A. Promote mobilization of fatty acids from adipose tissue Efx3eLtX1Ia8xzC/fjL6GA==
B. Result in increased glycogen storage by the liver AD2YBdbb6x3kfgtembjVpQ==
C. Stimulate β-oxidation by inhibiting the production of malonyl-CoA Efx3eLtX1Ia8xzC/fjL6GA==
D. Lead to increased concentrations of ketone bodies in the blood Efx3eLtX1Ia8xzC/fjL6GA==
Table
Correct.
Incorrect. You have not identified all correct answers. Review pages 678-679 about the regulation of fatty acid oxidation (particularly look at figure 17-13) as well as section 17.3 (about ketone body formation and utilization) of Lehninger 6E and please try again.
3
inv23
true

Question 7.26

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
5
Correct.
Try again.
Incorrect.
inv23
true

Question 7.27

What are some of the expected physiological consequences of a carnitine deficiency? (Select ALL that apply!)

A. Depletion of stored fat in adipocytes Efx3eLtX1Ia8xzC/fjL6GA==
B. Inability to metabolize short-chain fatty acids AD2YBdbb6x3kfgtembjVpQ==
C. High levels of circulating fatty acids Efx3eLtX1Ia8xzC/fjL6GA==
D. Chronic hypoglycemia when fasted Efx3eLtX1Ia8xzC/fjL6GA==
F. Impaired ability to produce ketone bodies Efx3eLtX1Ia8xzC/fjL6GA==
G. Inability to catabolize glucose to pyruvate AD2YBdbb6x3kfgtembjVpQ==
Table
5
Correct.
Incorrect. You should have selected four answer options as true. Review the details of this case and the specific role of carnitine in pages 670-671 of Lehninger 6E and please try again.
Incorrect.
inv23
true

Question 7.28

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
4
Correct.
Try again.
Incorrect.
inv23
true

Question 7.29

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
4
Correct.Though not investigated in this case, loss of β-oxidation can lead to fat deposition in muscle tissue as well for the same reason: arriving fatty acids cannot be oxidized and so are instead stored in muscle tissue.
Try again.
Incorrect.
inv23
true

Question 7.30

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
4
Correct.
Try again.
Incorrect.
inv23
true

Question 7.31

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
4
Correct.
Try again.
Incorrect.
inv23
true

Question 7.32

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
4
Correct.
Try again.
Incorrect.
inv23
true

Question 7.33

Based on all the evidence you have gathered in this case, and your answers to previous questions, what do you think caused Jessie’s fainting episode? (Select ALL the relevant factors that should be included in a complete explanation of her biochemical/medical issues!)

A. Jessie’s medication Efx3eLtX1Ia8xzC/fjL6GA==
B. Jessie’s diet in the days leading up to the episode Efx3eLtX1Ia8xzC/fjL6GA==
C. Jessie is a Type II diabetic AD2YBdbb6x3kfgtembjVpQ==
D. Jessie’s diet the day of the episode Efx3eLtX1Ia8xzC/fjL6GA==
E. Jessie has an inborn error of metabolism that affects lipid transport AD2YBdbb6x3kfgtembjVpQ==
F. Jessie is a type I diabetic AD2YBdbb6x3kfgtembjVpQ==
G. Jessie has chronic hypoglycemia as a result her inability to adequately metabolize most fatty acids Efx3eLtX1Ia8xzC/fjL6GA==
H. Jessie lost consciousness due to severe hypoglycemia because the overexertion from her swim further depleted her blood glucose Efx3eLtX1Ia8xzC/fjL6GA==
Table
4
Correct.
Incorrect. You should have selected five answer options as true. Please review the details of this case and try again.
Incorrect.
inv23
true

Question 7.34

EW7nxR+bm7NByEODtATx7nF7DNy2BjsahNb2HXJU8M9KbylRxPUT8TR75QxrWdMCbrZt7Oxd1frUMp7Fab8xnmw0rxisP63wy133DPoXwWXhv3UMhPNULIrjKU6qL9+jCOHJXpRGTOG2bGNGOlTX61/ZesoTKWKM1NfXgXsUe1dc9I76glrDqox4m5OLB+qmC6LdoPowyDvfB18gIT66AFJjjJn8A5yMfRcopEiD0K+vL7MuM4JWkvU6ixyWNg9ZYTvh2blitTfWes35ltWrn+gEsHNHSnCKed2oT602vLlPh3u6Vza5dIsrYXxW5WKzpYgrPwyABr2lOqnSmKjUI6lmm5bsZlWHSBJf9ZjqWBzK8BTGrYfGBvddiZLj8bOf+WZeLsLherk2CsXAtKSZboXOfIZXiTDDv8ZIgVmDWkcHLPa78TL8HN9n4aZ22HlZLi+V5069Ax3pVUro5oMdnBYOs/WmhFykCnxFFIr6q7wgfcJCNETWKgf71jR22t7uQDJ3agmgxaPFKTXJqyPRTZdfGzBS9klF992BvtLwYlB3TgH2MARUxvxkrBxfTPa1Lp/sIo34qVQQQY0fopqzDzSYcs2jGrH+DT+V0DCqUYoTky/05ppK3X+s9Lr3/UDwYJZIoET8bDJIa7cZ7iThrnMlIO/LZ9zT3D35DOgmgaQe48+Cjv/6M71E/e46UvpQXhiQOYj7yc47taOoiAnWvrc9eKMBB0Ls6PTf/xY5qnlSSqOQ3Kcmcg0+0OVKCvKifKl/ZWmqMmwfLP2P1aX7eC7ufp0yXjoFjtCL/P5V6C7USjIJzTPAj8zjeV7MYRIqKh+PDaaN294rF3NBZulWYVp1/u6HYWmECMncoPini6kudL5rhCx+LdDfHto57ks/I7uxBRtb7cWErxXVIlNluNUTNuxoHGPOgnkmbYBW5+v2y06qCQri4+PSPeDcMNxZSS+qF8Y71xTWGj4UX119dxEMWhha/jvkL6HZnUxemzzzZM21Kht4G0A9VuJAn4KLrsjTxzhjSZxBhJ4iB5YpBr2qVB5oJ2+FX0SmAEY4dPICPv4i6YPpQJsDUD+rkeEhGn9nREyv3cHCOcTRqRvplDyv1YVXJypUaQy2AaEbb+SHypY2a8xtD9E0ja/plWmBU5tjJf7iAtbfzZwDEe0N8vYYxipB1zRgDSsFj0t2fDa80Zp7uUs4nTm6mkTtNmujs0Q+9sk1HD7y3F2oG0h5xbsvH6OV2aF2g/uYx8iHlPEWcNjKleJ3CxLLWXAmhtuLL9EV2ZE+gS+m0VSw+OIBvZbr9uss+iKn9AMXQN0HHKU0IVYJjcPcdLwz1emY8IPmT7i8LzQ8A/r9qVLFunc7+IKbL/IwzY2YjpZ1lmLxviIegiwUFfRlK4FkRLHSTZ1BNvr4APmvuBsQTytlNkx7a/sye3gyj0yi8Rf32ivjgeSsMI/dk8w2oE4Im8OT3206zG1bxWpO7ILD1CK85MLviqqUtSTZWzceQy9qScKVuuLivmYyrjC5aK4hJe8eqo1AWwEC8y1blq+rsBFSTvU+OGddwWlNAtoH9d4iFGDoIejJJIzUbtDn33cPK/8xB6oB/CsnGURwEOCc79oZbefaVAwbZ3AbyHxJztx6s//Qv5GUpoaBs91UI9A2vx5o9Q32UsBwfKI6khCevXeTRpUG5BZgwTqWkGII5U0xNu+qtvhQImkDPw+DjfZG3Y0zRiL5wfA2yJ9DGx/1Mzwgol9T6cUxet99tvD6dOxvA5heNh0GhVZmBwr8McTq7xNA+kCFdr9g/wbl5ejaFZtziv1cAzcE8zwM3AwFhLvUzekgASopLpVIQttxBUGHDoh8dwqD1BHyVcpSz+2SnQcL4WolacGhlRvtBIewSzBvzTg9WC8bd/VWDQ93NLcj4lEDsaNZEbazPDN6xlsfMrxtUuvUjMQkqX6MP/1Q72e4s+YAwM2y6Fwv+JN/lDzvWFcZVoVES9//S7DbBXOw2/Hy+WRck+rWflbisxfL7D17frLGAXR4a+ZrEDoJKWxjpifjP10va/7ZjFGKXGEkg8HETEB8vTHR+HylodzkHKdB/Q7UKANbhvw1uNoMhbBQRUtv0D5nPI+uw7dx+hKEdwcWP+frc58OhtFyn+oZnO4QWYFHsrbV2THZa46HphO8DBsglz28tbL8p6lAACYUo8R6am1M+3awgT9Kfp9OStgl7kfMMgSDxnoGjWyDQw==
4
Correct.
Try again. Review the details of the case and chapter 17 (pages 667-688) of Lehninger 6E and please try again.
Incorrect.
inv23
true

Question 7.35

In your personal investigation of the case, you may or may not have discovered that Jessie had decreased levels of total blood protein and elevated levels of ammonia. Considering the metabolic consequences of her carnitine deficiency, why might this be? (Select ALL answers that would be part of a complete explanation!)

A. Ammonia is produced from short-chain fatty acid oxidation and inhibits protein synthesis AD2YBdbb6x3kfgtembjVpQ==
B. Because Jessie has reduced glycogen stores and hypoglycemia, her liver must run gluconeogenesis to provide glucose for the brain Efx3eLtX1Ia8xzC/fjL6GA==
C. Deamination of amino acids produces ammonia Efx3eLtX1Ia8xzC/fjL6GA==
D. Because Jessie cannot produce ketone bodies, her brain must rely solely on blood glucose as its source of energy Efx3eLtX1Ia8xzC/fjL6GA==
E. Normally, ketone bodies may be converted into glucose to feed the brain, but Jessie cannot make ketone bodies, so she cannot make glucose from this source and has to degrade proteins in order to do so AD2YBdbb6x3kfgtembjVpQ==
F. Under starvation conditions, non-essential proteins are catabolized to release glucogenic amino acids which can be deaminated to provide carbon skeletons that serve as gluconeogenic substrates Efx3eLtX1Ia8xzC/fjL6GA==
Table
4
Correct.
Incorrect. You should have selected four answer options as true. Although you may not have yet covered these sections, you may also wish to look at pages 696, 711, and 956-958 of Lehninger 6E to best answer this question. Please review these sections and try again.
Incorrect.

7.7 Summary

Congratulations on completing this Case Study! The following Case Summary gives a full explanation of Jessie's condition.

Case Summary

Jessie was suffering from a deficiency of carnitine, caused by a combination of her vegan diet and her long-term use of the anticonvulsant drug valproic acid, which depletes the body’s stores of carnitine. Carnitine is synthesized in the liver and kidney from amino acid precursors, especially lysine. Carnitine deficiencies can also occur in people undergoing regular renal hemodialysis (which increases excretion of carnitine) or in people taking drugs for AIDS or long-term bacterial infections, which can deliver toxic insults to liver or kidneys. Dietary sources of carnitine include meat and dairy products; Jessie, as a vegan, was taking in little carnitine from her diet.

Lack of carnitine caused Jessie’s muscles to lose the ability to use fatty acids as substrates for β-oxidation; without sufficient carnitine, the fatty acids cannot be converted from fatty acyl-CoA to fatty acyl-carnitine, which can enter the mitochondrial matrix, where the enzymes of β-oxidation are located. The result is a decrease in ATP made from oxidative metabolism. The unused fatty acids are stored (in the form of triglycerides) in liver and muscle tissue. Short-chain fatty acids of 12 carbons or less, do not require a carrier to enter the matrix, so such fatty acids can serve as β-oxidation substrates, and ketone bodies can be generated from the acetyl-CoA generated from this catabolic process. However, these fatty acids are relatively rare in the human diet and the majority of fatty acids stored in triglycerides are long-chain fatty acids. The inability to use long-chain fatty acids as fuel leads to higher use of glucose. Secretion of glucagon, as glucose is depleted, causes triacylglycerol stores to be mobilized, leading to an increase in fatty acids in the blood (carried by serum albumin.) With a carnitine deficiency, ketones are not made from the breakdown of fatty acids, so there is no increase in ketones seen during the fasting. In normal patients, ketones increase as glucose levels drop and fatty acids become the primary fuel for muscle. Finally, without the ATP generated from β-oxidation, there may be a lack of energy to generate glucose through the process of liver gluconeogenesis.

That fateful day, Jessie had also skipped breakfast and lunch, and so she was particularly hypoglycemic, and glycogen-depleted, before she started her heroic swim. The strenuous swim triggered glucose uptake by her muscles. The glucose used by her muscles could not be supplemented or replaced by stored glycogen, fatty acid metabolism, or ketone body formation, and therefore her blood glucose dropped to levels that cause loss of consciousness.

Finally, there are also genetic conditions that can lead to carnitine deficiencies. Examples are the lack of a functional enzyme in the carnitine biosynthesis pathway, defective transport proteins to allow entry of carnitine into the heart and muscle cells, and defective reabsorption of carnitine at the renal tubule. However, until her head injury and pharmacological intervention via valproic acid to prevent seizures, Jessie showed no symptoms, and was in fact a high-end athlete, making genetic conditions less likely as the basis for her carnitine deficiency.