Classical galactosemia is an autosomal recessive disorder of galactose metabolism occurring due to deficiency of the enzyme galactose-l-phosphate uridyl transferase (Gal-1-PUT), and responding to a galactose restricted diet [1]. In the absence of this enzyme, galactose is converted into toxic by-products (galactitol, galactose-1-phosphate and galactonate) that affect the liver, brain, kidneys, lens and gonads. There is scarcity of data on clinical profile and natural history among Indian children, resulting in lack of awareness of this potentially treatable condition. We studied the presentation and predictors of outcome of children diagnosed to have galactosemia.

We analyzed the data of children with confirmed galactosemia from July, 2003 to June, 2014 admitted in the Pediatric Gastroenterology department of our Institution, a large referral hospital in Northern India. Enrolled patients fulfilled all three diagnostic criteria: (i) clinical features suggestive of galactosemia, (ii) reduced or undetectable erythrocyte Gal-1-PUT enzyme activity, and (iii) unequivocal response to lactose-free diet. We retrieved the clinical, laboratory features and follow-up data from hospital electronic records. We traced majority of our patients telephonically for a fresh visit to document the current status at the time of analysis. At admission, all children underwent routine blood tests and screening for sepsis. Neutrophilia and leucocytosis were interpreted as per the age-related cut-offs (maximum limit of range) [2]. Diagnostic paracentesis was done in all patients with ascites. Presence of cataract was confirmed by the ophthalmologist with direct ophthalmoscopy. While on lactose containing diet at admission, three samples of urine were tested for presence of non-glucose reducing substances by Benedict’s test (glycosuria ruled out by urine dipstick method). Gal-1-PUT assay was done by spectrofluorometry (quantitative Beutler test) [3]. Normal values of Gal-1-PUT varied between 20-50 U/gHb. Levels £10 U/gHb are considered confirmatory of galactosemia. Values <5 U/gHb (lowest laboratory limit) were reported undetectable. The test was reconfirmed after 12 weeks of initial presentation in children who had earlier received packed red cell transfusion or had presented with hemolysis. Percutaneous liver biopsy was done at admission in all patients in whom the coagulopathy corrected and ascites resolved. Additionally, upper gastrointestinal endoscopy was performed as indicated. Pediatric end-stage liver disease (PELD) scores were calculated as per standard formula and scores of 17 and 25 were taken as cut-offs for comparison of various parameters [4,5]. Systemic infection was defined as any one or more of the following: (a) bacterial or fungal culture positivity of blood and/or urine, (b) pneumonia on chest X-ray, (c) cerebrospinal fluid analysis suggestive of pyogenic meningitis, (d) spontaneous bacterial peritonitis (SBP) or culture negative neutrocytic ascites (CNNA). SBP was defined as absolute neutrophil count ³250 cells/mm3 and ascitic fluid culture positivity. CNNA was defined as absolute neutrophil count ³250 cells/mm3 with sterile ascitic fluid culture [6]. Presumed infection in a sick child was defined as high clinical suspicion with neutrophilic leukocytosis with (out) thrombocytopenia (platelet count <100,000/mm3) with (out) positive semi-quantitative C-reactive protein (>6 mg/dL) but sterile body fluid cultures.

TABLE I 	Clinical Profile of Patients with Galactosemia  at Admission (N=24)

Liver function tests profile (median with range) showed total/direct bilirubin: 10.8 (2.8-24)/5.0(1.6-12.0) mg/dL, aspartate/ alanine aminotransferase: 191 (52-861)/84(26-525) U/L; serum albumin: 2.7 (1.9-4.2) g/dL; alkaline phosphatase: 937(143-1464) U/L; gamma-glutamyl transpeptidase: 24 (8-818) (U/L), and international normalized ratio (after vitamin K): 1.7 (1.0-6.8). Positive urinary non-glucose reducing substance samples (³2 of 3) were seen in 22 cases. Only two children had Gal-1-PUT levels of 8.7 and 10 U/gHb; rest 22 had undetectable levels. Twelve of 14 liver biopsies done showed cirrhosis or bridging fibrosis; 2 had macrovesicular steatosis. Median (range) PELD score at diagnosis was 24 (9-51).

TABLE II  Profile of Infections First at Admission And Readmission in Non-compliant Patients 

Table II shows the composite infectious profile of all infected patients. 13 children with systemic infection had a definitive infective focus at admission. Additionally 4 infants initially stable were readmitted with systemic infection at follow-up as they were non-compliant to LFD. 11/17 (68%) systemic infection had a gram negative infection, mostly with Escherichia coli (n=8). Symptom onset <2 weeks of age (n=5) was significantly associated with systemic infection (P=0.002) than those with >2 weeks (n=8). PELD ³25 at first admission was significantly associated with systemic infection (p=0.04, or 7.0, 95% CI 1.04-46.9).

Fig. 1 shows the natural history of galactosemia patients on follow-up. Mean days of hospitalization was 12 (4-23) d. Long term follow-up (³6 months) was available in 18 patients who had good LFD compliance and were analyzed for outcome. LFT improved in 4.5 (1-18) and 15 (4-24) mo in those diagnosed <4 weeks (n=12) and >4 weeks (n=6) of age, respectively (P=0.02). No difference in LFT normalization was seen with PELD cut-off scores of 17 or 25.

Fig. 1 Clinical course and outcome of galactosemia patients.

One child operated at 8 months was permanently blind due to irreversible amblyopia. Thirteen children older than 18 months age were assessed for development. Of 6 with initial language delay, two showed catch-up at subsequent follow-up. Hypodensities in white matter on imaging with persistent fine motor delay at 24 months was noted in one child.

This composite study reported the presentation, natural history and predictors of outcome in galactosemia among Indian children. Though the exact Indian prevalence is not known, galactosemia constituted 2% of all our neonatal cholestasis referrals. In an analysis of 1008 cases of neonatal cholestasis, galactosemia constituted 4% of all cases and 35% in the metabolic liver disease sub-group [7]. Our median age of diagnosis was comparable to that reported by Singh, et al. [8]. Delay in diagnosis resulted in higher hepatocellular dysfunction (100% vs. 64-89%), systemic infection (71% vs. 13-40%), cataract (54% vs. 13-30%) and seizures (29% vs. 3-17%) in our study compared to other series where early referral was attributable to neonatal screening [9,10]. In the study by Honeyman, et al. [10], 95% neonates were started on LFD by day 30 of life .

E.coli culture positivity was higher in our series (47% vs. 24%) compared to Waggoner, et al. [9]. Transplecental deficiency of IgM bactericidal opsonic antibodies-complement system in neonates and inhibition of leucocyte bactericidal activity by accumulated galactose predispose to gram-negative infections [11,12].

The disease has a favorable prognosis by timely referral, introduction of LFD, and long term compliance; Reintroduction of lactose in such cases may be fatal [13]. LFT improved by median interval of 5.5(1-24) months of starting therapy, significantly earlier in those diagnosed <4 weeks. PELD cut-off’s >17 (United Network for Organ Sharing Status for liver transplant) and >25 (high incidence of death rate: 4.6/1000 patient-years) did not influence the improvement in LFT at follow-up [3,4]. Spontaneous resolution of cataract was not related to age at diagnosis or dietary intervention. This is in contrast to Waggoner, et al. [9] who showed that 90% cataracts resolve spontaneously if dietary intervention is begun at mean of 77 days of age [9]. Given the risk of irreversible ambylopia, early cataract surgery (1-8 weeks of life) is presently recommended by most pediatric ophthalmologists as performed in seven of our cases who continued to have dense cataract despite four weeks of LFD [14].

Bosch, et al. [15] found subnormal cognitive outcomes in galactosemia children older than six years age, despite strict adherence to diet [15]. Small number of patients and retrospective design were the main limitations of our study. As a result, we could not assess IQ, use development scoring systems or identify risk factors for delayed milestones.

A cholestatic neonate with ascites, coagulopathy, seizures, family history of sibling death, consanguinity and/or hemolysis should raise a suspicion for galactosemia. Despite high PELD scores (advanced disease) and systemic infections, this condition is salvageable with lactose-free diet. Neonatal screening or early diagnosis are helpful strategies to having a favorable outcome.