HMGCL and hyperinsulinemic hypoglycemia, familial, 4: Furthermore, Ozand et al. (1991) have reported overlapping clinical presentations, where 11 Saudi infants suffered from HMG-CoA lyase deficiency, with clinical presentation of acidotic attack including hyperpnea, lethargy, seizures, and tachypnea, at either birth or refusal of food in later infancy (Ozand et al., 1991).