{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:30:28Z","timestamp":1787027428781,"version":"build-2736575974"},"reference-count":18,"publisher":"MDPI AG","issue":"16","license":[{"start":{"date-parts":[[2026,8,15]],"date-time":"2026-08-15T00:00:00Z","timestamp":1786752000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003196","name":"Italian Ministry of Health","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100003196","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Int. J. Mol. Sci.","IJMS"],"abstract":"<jats:p>Multiple acyl-CoA dehydrogenase deficiency (MADD) is considered an autosomal recessive disorder; yet, recent findings suggest up to 10% of cases may result from heterozygous electron transfer flavoprotein dehydrogenase (ETFDH) variants exhibiting dominant or dominant-like effects. Here, a novel heterozygous ETFDH variant (c.1798A&gt;C, p.Asn600His) was identified within a three-generation family. The grandfather presented with muscular weakness at age 35, and the father developed similar symptoms at 19 following a tonsillectomy. Both were diagnosed with MADD based on muscle biopsies revealing neutral lipid accumulation and acylcarnitine profiles and responded fully to riboflavin therapy (150 mg\/day). The two siblings, aged 8 and 10, carry the same mutation and show increased acyl-carnitine levels but remain asymptomatic due to early riboflavin treatment. Skin fibroblasts from affected individuals were immortalized and subjected to normal and reduced riboflavin levels. Gene expression analysis demonstrated unchanged ETFDH RNA but reduced protein levels in mutant cells, particularly under low riboflavin. Structural modelling suggested the Asn600His substitution destabilizes the protein, diminishing its mitochondrial function. Proximity ligation assays indicated a decreased interaction with mitochondrial complex III, while oxygen consumption via fatty acid oxidation was impaired, especially at reduced riboflavin. The novel ETFDH variant found in this family gives a possible dominant pattern of inheritance for MADD, where a single mutant allele impairs the mitochondrial metabolism, particularly under riboflavin-deficient conditions, and highlights the importance of early riboflavin supplementation in preventing clinical symptoms.<\/jats:p>","DOI":"10.3390\/ijms27167294","type":"journal-article","created":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T12:01:26Z","timestamp":1786968086000},"page":"7294","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A Family Exhibiting Autosomal Dominant Inheritance of Multiple Acyl-Coenzyme A (CoA) Dehydrogenase Deficiency (MADD) Disease"],"prefix":"10.3390","volume":"27","author":[{"given":"Francesco","family":"Baldo","sequence":"first","affiliation":[{"name":"Division of Metabolic Diseases and Hepatology, Bambino Ges\u00f9 Childrens Hospital IRCCS, 00165 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6692-6573","authenticated-orcid":false,"given":"Elena","family":"Genova","sequence":"additional","affiliation":[{"name":"Institute for Maternal and Child Health\u2014IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0110-5942","authenticated-orcid":false,"given":"Valeria","family":"Capaci","sequence":"additional","affiliation":[{"name":"Institute for Maternal and Child Health\u2014IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-0673-7278","authenticated-orcid":false,"given":"Irene","family":"Marrone","sequence":"additional","affiliation":[{"name":"Institute for Maternal and Child Health\u2014IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nour","family":"Balasan","sequence":"additional","affiliation":[{"name":"Institute for Maternal and Child Health\u2014IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8101-9659","authenticated-orcid":false,"given":"Anna Monica","family":"Bianco","sequence":"additional","affiliation":[{"name":"Institute for Maternal and Child Health\u2014IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5886-9129","authenticated-orcid":false,"given":"Luisa","family":"Zupin","sequence":"additional","affiliation":[{"name":"Institute for Maternal and Child Health\u2014IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Irene","family":"Bruno","sequence":"additional","affiliation":[{"name":"Institute for Maternal and Child Health\u2014IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8024-0482","authenticated-orcid":false,"given":"Maria Teresa","family":"Bonati","sequence":"additional","affiliation":[{"name":"Institute for Maternal and Child Health\u2014IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9760-8463","authenticated-orcid":false,"given":"Fulvio","family":"Celsi","sequence":"additional","affiliation":[{"name":"Institute for Maternal and Child Health\u2014IRCCS \u201cBurlo Garofolo\u201d, 34137 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"145407","DOI":"10.1016\/j.gene.2021.145407","article-title":"Electron Transfer Flavoprotein and Its Role in Mitochondrial Energy Metabolism in Health and Disease","volume":"776","author":"Henriques","year":"2021","journal-title":"Gene"},{"key":"ref_2","unstructured":"Adam, M.P., Bick, S., Mirzaa, G.M., Pagon, R.A., Wallace, S.E., and Amemiya, A. (1993). Multiple Acyl-CoA Dehydrogenase Deficiency. GeneReviews\u00ae, University of Washington."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1186\/s13023-025-03845-7","article-title":"The Difference of Variation Types between Late-Onset Multiple Acyl-CoA Dehydrogenase Deficiency Patients Carrying Biallelic and Single Heterozygous Variations in ETFDH: A Systematic Review and Meta-Analysis","volume":"20","author":"Zhang","year":"2025","journal-title":"Orphanet J. Rare Dis."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Chokchaiwong, S., Kuo, Y.-T., Hsu, S.-P., Hsu, Y.-C., Lin, S.-H., Zhong, W.-B., Lin, Y.-F., and Kao, S.-H. (2019). ETF-QO Mutants Uncoupled Fatty Acid \u03b2-Oxidation and Mitochondrial Bioenergetics Leading to Lipid Pathology. Cells, 8.","DOI":"10.3390\/cells8020106"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1038\/s42255-023-00956-y","article-title":"An ETFDH-Driven Metabolon Supports OXPHOS Efficiency in Skeletal Muscle by Regulating Coenzyme Q Homeostasis","volume":"6","author":"Calvo","year":"2024","journal-title":"Nat. Metab."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"148417","DOI":"10.1016\/j.bbabio.2021.148417","article-title":"The Modified Q-Cycle: A Look Back at Its Development and Forward to a Functional Model","volume":"1862","author":"Crofts","year":"2021","journal-title":"Biochim. Biophys. Acta BBA Bioenerg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"8894","DOI":"10.1021\/bi800507p","article-title":"The Iron-Sulfur Cluster of Electron Transfer Flavoprotein-Ubiquinone Oxidoreductase (ETF-QO) Is the Electron Acceptor for Electron Transfer Flavoprotein","volume":"47","author":"Swanson","year":"2008","journal-title":"Biochemistry"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"3435","DOI":"10.1093\/hmg\/dds175","article-title":"Molecular Mechanisms of Riboflavin Responsiveness in Patients with ETF-QO Variations and Multiple Acyl-CoA Dehydrogenation Deficiency","volume":"21","author":"Cornelius","year":"2012","journal-title":"Hum. Mol. Genet."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1038\/s41586-024-07487-w","article-title":"Accurate Structure Prediction of Biomolecular Interactions with AlphaFold 3","volume":"630","author":"Abramson","year":"2024","journal-title":"Nature"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"eadg7492","DOI":"10.1126\/science.adg7492","article-title":"Accurate Proteome-Wide Missense Variant Effect Prediction with AlphaMissense","volume":"381","author":"Cheng","year":"2023","journal-title":"Science"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Er, T.-K., Chen, C.-C., Liu, Y.-Y., Chang, H.-C., Chien, Y.-H., Chang, J.-G., Hwang, J.-K., and Jong, Y.-J. (2011). Computational Analysis of a Novel Mutation in ETFDH Gene Highlights Its Long-Range Effects on the FAD-Binding Motif. BMC Struct. Biol., 11.","DOI":"10.1186\/1472-6807-11-43"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1002\/ana.25338","article-title":"ETFDH Mutations and Flavin Adenine Dinucleotide Homeostasis Disturbance Are Essential for Developing Riboflavin-Responsive Multiple Acyl-Coenzyme A Dehydrogenation Deficiency","volume":"84","author":"Xu","year":"2018","journal-title":"Ann. Neurol."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Lupica, A., Oteri, R., Volta, S., Ghezzi, D., Drago, S.F.A., Rodolico, C., Musumeci, O., and Toscano, A. (2022). Diagnostic Challenges in Late Onset Multiple Acyl-CoA Dehydrogenase Deficiency: Clinical, Morphological, and Genetic Aspects. Front. Neurol., 13.","DOI":"10.3389\/fneur.2022.815523"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Zoppi, D., Russo, A., Vallefuoco, F., Maria, M.D., Esposito, G., Fioretti, T., Maiolo, V., Santorelli, F.M., Iodice, R., and Tozza, S. (2025). Late-Onset Multiple Acyl-CoA Dehydrogenase Deficiency (MADD): Clinical Features, Diagnostic Challenges, and the Role of Oxidative Stress in Pathophysiology. Antioxidants, 14.","DOI":"10.3390\/antiox14121409"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1002\/humu.10226","article-title":"Clear Relationship between ETF\/ETFDH Genotype and Phenotype in Patients with Multiple Acyl-CoA Dehydrogenation Deficiency","volume":"22","author":"Olsen","year":"2003","journal-title":"Hum. Mutat."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1021\/bi701859s","article-title":"Impact of Mutations on the Midpoint Potential of the [4Fe-4S]+1,+2 Cluster and on Catalytic Activity in Electron Transfer Flavoprotein-Ubiquinone Oxidoreductase (ETF-QO)","volume":"47","author":"Usselman","year":"2008","journal-title":"Biochemistry"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1016\/S1096-7192(03)00109-4","article-title":"Pathogenic Mutations in the Carboxyl-Terminal Domain of Glutaryl-CoA Dehydrogenase: Effects on Catalytic Activity and the Stability of the Tetramer","volume":"79","author":"Westover","year":"2003","journal-title":"Mol. Genet. Metab."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2037","DOI":"10.1093\/brain\/awm054","article-title":"The Myopathic Form of Coenzyme Q10 Deficiency Is Caused by Mutations in the Electron-Transferring-Flavoprotein Dehydrogenase (ETFDH) Gene","volume":"130","author":"Gempel","year":"2007","journal-title":"Brain"}],"container-title":["International Journal of Molecular Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1422-0067\/27\/16\/7294\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:16:08Z","timestamp":1787026568000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1422-0067\/27\/16\/7294"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,15]]},"references-count":18,"journal-issue":{"issue":"16","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["ijms27167294"],"URL":"https:\/\/doi.org\/10.3390\/ijms27167294","relation":{},"ISSN":["1422-0067"],"issn-type":[{"value":"1422-0067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,15]]}}}