The term congenital lactic acidosis (CLA) refers to a group of inborn errors of mitochondrial metabolism variably characterised by progressive neuromuscular deterioration and accumulation of lactate and hydrogen ions in blood, urine and/or cerebrospinal fluid, frequently resulting in early death.1-4 The incidence and prevalence of CLA are unknown, although it has been estimated that there are approximately 250 new cases recognised in the US per year (personal communication). Thus, with an estimated annual mortality attrition rate of 20%, at least 1000 cases exist in the general US population.

Recent diagnostic advances have allowed the biochemical or molecular identification of specific enzyme defects in the majority of infants and children with CLA. Most identifiable cases involve inherited or spontaneous mutations in the pyruvate dehydrogenase complex (PDC) or in one or more enzymes of the respiratory chain.2 4 A few cases have been reported that involve deficiencies in enzymes of the tricarboxylic acid cycle, such as fumarase, or of gluconeogenesis, such as pyruvate carboxylase (PC) or phosphoenolpyruvate carboxykinase (PEPCK). In a substantial number of patients, however, the specific biochemical defect fails to be determined by established techniques.

Hyperlactataemia is the defining biochemical abnormality in children with CLA and, in the absence of hypoxia, should be considered a surrogate marker for underlying failure of mitochondrial energy metabolism.5 This concept is most readily appreciated by considering mitochondrial enzyme deficiencies. Figure 1 summarises the major steps of carbohydrate oxidation in mammalian cells. Note that the oxidative fate of pyruvate is to be irreversibly decarboxylated to acetyl CoA. This reaction is catalysed by PDC, a series of linked enzymes located in the inner mitochondrial membrane (fig 2). Under aerobic conditions, the activity of PDC determines the rate at which all cells oxidise glucose, pyruvate, and lactate.