mitochondrial respiratory chain dysfunction ( 1-4 ). It results from loss-of-function mutations of the tafazzin ( TAZ ) gene ( 5 ).The major consequence of this loss-of-function is the defi cient remodeling of the mitochondrial phospholipid cardiolipin (CL), a process that normally leads to the mature acyl composition ( 6, 7 ). CL is the signature lipid of mitochondria, where it is an important constituent of the inner membrane, essential for supercomplex formation, oxidative phosphorylation (i.e., mitochondrial energy metabolism), and protein import, and is capable of triggering mitophagy and mitochondria-mediated apoptosis (8)(9)(10)(11)(12)(13)(14)(15)(16). Because the remodeling of CL is deficient in BTHS, biochemical abnormalities in patients include a decreased level of mature CL (CLm), an increased level of monolysocardiolipin (MLCL), and altered CL acyl composition [i.e., the presence of immature CL (CLi) species].Historically, the diagnosis of BTHS has relied on identifi cation of the clinical symptoms accompanied by neutropenia and 3-MGCA and has then been confi rmed by the fi nding of TAZ mutations. More recently, assays of CL alone or of the ratio of CL to MLCL have been used in Europe. However, each of these diagnostic approaches has problems. There are multiple reports of false-negative disease detection by urinary organic acid screening ( 4 ). TAZ sequencing is relatively slow and expensive, and CL analysis involves many steps including extraction of lipids and isolation of CL molecular species by complex chromatographic techniques. Consequently, although measurement of CL/MLCL ratio has 100% diagnostic sensitivity and specifi city, it is only available in a few clinical laboratories