Article Text

Download PDFPDF
Original research
Subclinical ochronosis features in alkaptonuria: a cross-sectional study
  1. Trevor Cox1,
  2. Eftychia Eirini Psarelli2,
  3. Sophie Taylor3,
  4. Hannah Rose Shepherd4,
  5. Mark Robinson5,
  6. Gabor Barton5,
  7. Alpesh Mistry6,
  8. Federica Genovese7,
  9. Daniela Braconi8,
  10. Daniela Giustarini9,
  11. Ranieri Rossi9,
  12. Annalisa Santucci8,
  13. Milad Khedr10,
  14. Andrew Hughes11,
  15. Anna Milan11,
  16. Leah Frances Taylor12,
  17. Elizabeth West13,
  18. Nicolas Sireau14,
  19. Jane Patricia Dillon15,
  20. Nicholas Rhodes16,
  21. James Anthony Gallagher15,
  22. Lakshminarayan Ranganath17
  1. 1 Molecular and Clinical Cancer Medicine, Liverpool University, Liverpool, UK
  2. 2 LCTU, University of Liverpool, School of Life Sciences, Liverpool, UK
  3. 3 Physiotherapy, Royal Liverpool University Hospital, Liverpool, Merseyside, UK
  4. 4 Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
  5. 5 School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
  6. 6 Musculoskeletal Radiology, Royal Liverpool University Hospital, Liverpool, UK
  7. 7 Nordic Bioscience A/S, Herlev, Denmark
  8. 8 Biotecnologie Chimica e Farmacia, Universita degli Studi di Siena Dipartimento di Biotecnologie Chimica e Farmacia, Siena, Italy
  9. 9 Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
  10. 10 Department of Clinical Chemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
  11. 11 Clinical Biochemistry, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
  12. 12 College of Clinical and Biomedical Science, University of Central Lancashire, Preston, UK
  13. 13 Dermatology, Royal Liverpool University Hospital, Liverpool, UK
  14. 14 AKU Society, Cambridge, UK
  15. 15 Musculoskeletal Biology, University of Liverpool, Institute of Ageing and Chronic Disease, Liverpool, UK
  16. 16 Musculoskeletal Biology, University of Liverpool, Liverpool, UK
  17. 17 Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool, UK
  1. Correspondence to Dr Lakshminarayan Ranganath, Clinical Biochemistry and Metabolic Medicine, Royal Liverpool University Hospital, Liverpool L7 8XP, UK; lrang{at}


Background Alkaptonuria (AKU) is present from birth, yet clinical effects are considered to appear later in life. Morbidity of AKU, considered irreversible, is secondary to ochronosis. Age of ochronosis onset is not clearly known. Nitisinone profoundly lowers homogentisic acid (HGA), the metabolic defect in AKU. Nitisinone also arrests ochronosis and slows progression of AKU. However, tyrosinaemia post-nitisinone has been associated with corneal keratopathy, rash and cognitive impairment in HT 1. The optimal time to start nitisinone in AKU is unknown.

Methods In an open, cross-sectional, single-site study, 32 patients with AKU were to be recruited. The primary outcome was presence of ochronosis in an ear biopsy. Secondary outcomes included analysis of photographs of eyes/ears, serum/urine HGA, markers of tissue damage/inflammation/oxidation, MRI imaging, gait, quality of life and Alkaptonuria Severity Score Index (qAKUSSI).

Results Thirty patients, with mean age (SD) 38 (14) years, were recruited. Percentage pigmentation within ear biopsies increased with age. Ear pigmentation was detected in a 20-year-old woman implying ochronosis can start in patients before the age of 20. Gait and qAKUSSI were outside the normal range in all the patients with AKU.

Conclusions Ochronosis can be present before age 20 years.

  • alkaptonuria
  • ochronosis
  • natural history
  • ear cartilage biopsy

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors TC, JAG and LR: design of the study and manuscript writing. NS and NR: grant writing and conduct of the study. JAG and JPD: analysis of ear biopsy and qualitative scoring of eye ochronosis. JAG and LFT: quantitative analysis of eye ochronosis. EW: ear biopsies. AnM and AH: assay of HGA. AlM: scoring of MRI. GB, HRS and MR: gait analysis. FG: bone and cartilage biomarkers. DB, DG, RR, AS: inflammatory markers. MK: quality of life assessments. ST: analysis of questionnaires. AH: HGA assays. TC and EEP: statistical analysis. TC: first drafting and revision of the manuscript. NR was involved in obtaining grant funding and writing of the manuscript. All authors contributed to analysis of the data, edited the manuscript and approved the final version.

  • Funding This work was supported by European Commission Seventh Framework Programme funding granted in 2012 (DevelopAKUre, project no. 304985). Additional support was received from the UK National AKU Centre, funded by NHS England Highly Specialized Services.

  • Disclaimer The authors confirm independence from the sponsors; the content of the article has not been influenced by the sponsors. The funding source was not involved in the study design, collection, analysis and interpretation of data, the writing of the manuscript or in the decision to submit the manuscript for publication.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Ethics approval UK Research Ethics Committee (REC) no. 15/NW/0749. Integrated Research Application System (IRAS) Project ID: 180968.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as online supplementary information.