1. Methemoglobinemia: The real cause of the Blue People of Kentucky

2. History
Martin Fugate, a French orphan, married Elizabeth Smith and settled along the Troublesome Creek in Kentucky.
The family had seven children, four were reported to have blue skin.
Martin was thought to be blue, and his wife a carrier for the recessive trait. The odds of this occurring in society is almost incalculable.

3. Fugate Family

4. History
Since the family lived along the mountainside, houses were few and far between and eventually led to Fugates’ marrying Fugates’.
They also married the families which lived closest to them which included: Combses, Smiths, Ritchies, and Stacys
To them it was only natural to marry the girl next door (even if it was your first cousin).

5. Pedigree of Fugate Family

6. Pedigree of Fugate Family

7. History
Several years later, Zachariah, a blue boy, married his mother’s sister, who must have been a carrier also.
Over one hundred years later, this line of succession led to the birth of Benjy Stacy, in 1975.
Upon birth he was reported to be completely purple but later turned to natural skin color.
Today, only his lips and fingernails remain blue in color.

8. Another Fugate Pedigree
Pedigree of the Fugates of Troublesome Creek
as gleaned from the Science 82 article
                                                                                                                                                   

9. Biological Aspects
This disorder results from a deficiency of NADH-cytochrome b5 reductase, which is also referred to as NADH diaphorase.
Most enzyme deficiencies are inborn errors of metabolism, and are inherited as recessive traits. Whereas structural defects, such as brachydactyly and structural anomalies of nonenzymatic proteins are usually inherited as dominant.

10. Biological Aspects (cont’d)
Red blood cells are deficient in NADH diaphorase activity and cannot reduce the oxidized iron in methemoglobin (metHb).
The red blood cells from the parents of a blue child contain some NADH diaphorase activity but not much.

11. Methemoglobinemia Pictures

12. Three Types of Methemoglobinemia
There are three possible manifestations of this disorder, varying in severity.
Type I: Erythrocytic, only symptom is cyanosis due to increased methemoglobin
Type II: Enzymatic deficiency in all tissues, results in mental retardation and other neurological defects
Type III: Similar symptoms to type I, but decreased enzyme activity in ALL blood cells

13. Type I
The Blue People of Kentucky suffer from type I methemoglobinemia
This is caused by a single substitution mutation.
R57Q, V105M
Different mutations in the same gene can result in varying levels of severity

14. NADH-cytochrome b5 reductase
This enzyme transfers two electrons from NADH to two molecules of cytochrome b5 via an enzyme bound FAD.
NADH and FAD are bound to two different branches of the enzyme
Cytochrome b5 transfers the electrons to a variety of acceptors

15. Structure

16. Pathway

17. Soluble v. Membrane Bound
Mutation in the soluble form of NADH-cytochrome b5 reductase is responsible for type I and type III manifestations of methemoglobinemia
Mutation in the membrane bound form of the enzyme result in the much more severe type II phenotype which is a system wide disorder

18. Enzyme Stability
Mutant enzyme is less stable and more susceptible to proteinase treatment than wildtype.
This increased instability and susceptibility to proteinase, resulting in degradation.
Mutant enzyme is also heat sensitive.

19. NADH Diaphorase Enzyme

20. Enzyme Activity
NADH Diaphorase is the enzyme that uses NADH as the reducing agent.
Without the use of this enzyme, the iron molecule in methemoglobin can not be reduced to hemoglobin, the state in which O2 is transported in the blood.

21. NADH Diaphorase activity

22. Binding of Fe2+ to Heme
Binding of O2 in hemoglobin or myoglobin is to an Fe2+- containing HEME group (iron-porphyrin)

23. Treatment of the Disorder
Methylene blue was used to turn their skin back to normal color because it can act as an electron donor and reduce the iron to Fe2+.
This is a quick acting reaction and the effects are only temporary.

24. Pathway