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Hirano M, Carelli V, De Giorgio R, Pironi L, Accarino A, Cenacchi G, D’Alessandro R, Filosto M, Martí R, Nonino F, Pinna AD, Baldin E, Bax BE, Bolletta A, Bolletta R, Boschetti E, Cescon M, D’Angelo R, Dotti MT, Giordano C, Gramegna LL, Levene M, Lodi R, Mandel H, Morelli MC, Musumeci O, Pugliese A, Scarpelli M, Siniscalchi A, Spinazzola A, Tal G, Torres-Torronteras J, Vignatelli L, Zaidman I, Zoller H, Rinaldi R, Zeviani M. Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE): Position paper on diagnosis, prognosis, and treatment by the MNGIE International Network. J Inherit Metab Dis 2021; 44:376-387. [PMID: 32898308 PMCID: PMC8399867 DOI: 10.1002/jimd.12300] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/05/2023]
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare autosomal recessive disease caused by TYMP mutations and thymidine phosphorylase (TP) deficiency. Thymidine and deoxyuridine accumulate impairing the mitochondrial DNA maintenance and integrity. Clinically, patients show severe and progressive gastrointestinal and neurological manifestations. The onset typically occurs in the second decade of life and mean age at death is 37 years. Signs and symptoms of MNGIE are heterogeneous and confirmatory diagnostic tests are not routinely performed by most laboratories, accounting for common misdiagnosis. Factors predictive of progression and appropriate tests for monitoring are still undefined. Several treatment options showed promising results in restoring the biochemical imbalance of MNGIE. The lack of controlled studies with appropriate follow-up accounts for the limited evidence informing diagnostic and therapeutic choices. The International Consensus Conference (ICC) on MNGIE, held in Bologna, Italy, on 30 March to 31 March 2019, aimed at an evidence-based consensus on diagnosis, prognosis, and treatment of MNGIE among experts, patients, caregivers and other stakeholders involved in caring the condition. The conference was conducted according to the National Institute of Health Consensus Conference methodology. A consensus development panel formulated a set of statements and proposed a research agenda. Specifically, the ICC produced recommendations on: (a) diagnostic pathway; (b) prognosis and the main predictors of disease progression; (c) efficacy and safety of treatments; and (f) research priorities on diagnosis, prognosis, and treatment. The Bologna ICC on diagnosis, management and treatment of MNGIE provided evidence-based guidance for clinicians incorporating patients' values and preferences.
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Affiliation(s)
- Michio Hirano
- Department of Neurology, Columbia University Irving Medical Center, New York, New York
| | - Valerio Carelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Roberto De Giorgio
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Loris Pironi
- Clinical Nutrition and Metabolism Unit and Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Anna Accarino
- Digestive System Research Unit, University Hospital Vall d’Hebron / Centro de Investigación Biomédica en Red de Enfermeda des Hepáticas y Digestivas (CIBEREHD); Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Giovanna Cenacchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
| | | | - Massimiliano Filosto
- Center for Neuromuscular Diseases, Unit of Neurology, Azienda Socio Sanitaria Territoriale degli Spedali Civili and University of Brescia, Brescia, Italy
| | - Ramon Martí
- Vall d’Hebron Research Institute, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Autonomous University of Barcelona, Barcelona, Spain
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Bridget Elizabeth Bax
- Institute of Molecular and Clinical Sciences, St George’s University of London, London, UK
| | | | | | - Elisa Boschetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Matteo Cescon
- General Surgery and Transplant Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto D’Angelo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Interaziendale Metropolitana (NeuroMet), - Neurologia AOU S.Orsola-Malpighi, Bologna, Italy
| | - Maria Teresa Dotti
- Neurological and Metabolic Diseases Clinic, Siena Hospital, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Carla Giordano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza, University of Rome, Umberto I Policlinic, Rome, Italy
| | - Laura Ludovica Gramegna
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Michelle Levene
- Institute of Molecular and Clinical Sciences, St George’s University of London, London, UK
| | - Raffaele Lodi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Hanna Mandel
- Institute of Human Genetics and Inherited Metabolic Disorders, Galilee Medical Center, Nahariya, Israel
| | - Maria Cristina Morelli
- Department for Care of Organ Failures and Transplants, Internal Medicine for the Treatment of Severe Organ Failures, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Olimpia Musumeci
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alessia Pugliese
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Mauro Scarpelli
- Neurology Unit, Department of Neuroscience, Azienda Ospedaliero Universitaria Integrata Verona, Verona, Italy
| | - Antonio Siniscalchi
- Anaesthesiology Intensive Care and Transplantation Unit, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Antonella Spinazzola
- Department of Clinical Movement Neurosciences, Royal Free Campus, University College of London, Queen Square Institute of Neurology, London, UK
| | - Galit Tal
- Metabolic Unit, Ruth Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Javier Torres-Torronteras
- Vall d’Hebron Research Institute, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Autonomous University of Barcelona, Barcelona, Spain
| | - Luca Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Irina Zaidman
- Department of Bone Marrow Transplantation, Hadassah University Medical Center, Jerusalem, Israel
| | - Heinz Zoller
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Interaziendale Metropolitana (NeuroMet), - Neurologia AOU S.Orsola-Malpighi, Bologna, Italy
| | - Massimo Zeviani
- Department of Neurosciences, Veneto Institute of Molecular Medicine, University of Padova, Padova, Italy
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Bax BE. Mitochondrial neurogastrointestinal encephalomyopathy: approaches to diagnosis and treatment. JOURNAL OF TRANSLATIONAL GENETICS AND GENOMICS 2019; 4:1-16. [PMID: 32914088 PMCID: PMC7116056 DOI: 10.20517/jtgg.2020.08] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an ultra-rare disease caused by mutations in TYMP, the gene encoding for the enzyme thymidine phosphorylase. The resulting enzyme deficiency leads to a systemic accumulation of thymidine and 2’-deoxyuridine and ultimately mitochondrial failure due to a progressive acquisition of secondary mitochondrial DNA (mtDNA) mutations and mtDNA depletion. MNGIE is characterised by gastrointestinal dysmotility, cachexia, peripheral neuropathy, ophthalmoplegia, ptosis and leukoencephalopathy. The disease is progressively degenerative and leads to death at an average age of 37.6 years. Patients invariably encounter misdiagnoses, diagnostic delays, and non-specific clinical management. Despite its rarity, MNGIE has invoked much interest in the development of therapeutic strategies, mainly because it is one of the few mitochondrial disorders where the molecular abnormality is metabolically and physically accessible to manipulation. This review provides a resume of the current diagnosis and treatment approaches and aims to increase the clinical awareness of MNGIE and thereby facilitate early diagnosis and timely access to treatments, before the development of untreatable and irreversible organ damage.
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Affiliation(s)
- Bridget E Bax
- Institute of Molecular and Clinical Sciences, St. George's University of London, London, SW17 ORE, UK
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Pacitti D, Levene M, Garone C, Nirmalananthan N, Bax BE. Mitochondrial Neurogastrointestinal Encephalomyopathy: Into the Fourth Decade, What We Have Learned So Far. Front Genet 2018; 9:669. [PMID: 30627136 PMCID: PMC6309918 DOI: 10.3389/fgene.2018.00669] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/04/2018] [Indexed: 02/05/2023] Open
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an ultra-rare metabolic autosomal recessive disease, caused by mutations in the nuclear gene TYMP which encodes the enzyme thymidine phosphorylase. The resulting enzyme deficiency leads to a systemic accumulation of the deoxyribonucleosides thymidine and deoxyuridine, and ultimately mitochondrial failure due to a progressive acquisition of secondary mitochondrial DNA (mtDNA) mutations and mtDNA depletion. Clinically, MNGIE is characterized by gastrointestinal and neurological manifestations, including cachexia, gastrointestinal dysmotility, peripheral neuropathy, leukoencephalopathy, ophthalmoplegia and ptosis. The disease is progressively degenerative and leads to death at an average age of 37.6 years. As with the vast majority of rare diseases, patients with MNGIE face a number of unmet needs related to diagnostic delays, a lack of approved therapies, and non-specific clinical management. We provide here a comprehensive collation of the available knowledge of MNGIE since the disease was first described 42 years ago. This review includes symptomatology, diagnostic procedures and hurdles, in vitro and in vivo disease models that have enhanced our understanding of the disease pathology, and finally experimental therapeutic approaches under development. The ultimate aim of this review is to increase clinical awareness of MNGIE, thereby reducing diagnostic delay and improving patient access to putative treatments under investigation.
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Affiliation(s)
- Dario Pacitti
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Michelle Levene
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Caterina Garone
- MRC Mitochondrial Biology Unit, Cambridge Biomedical, Cambridge, United Kingdom
| | | | - Bridget E. Bax
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
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Anuras S, Anuras J. Clinical Manifestations of Severe Gastrointestinal Motility Disturbance. J Intensive Care Med 2016. [DOI: 10.1177/088506668800300206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Severe gastrointestinal motility disturbance, or pseu doobstruction, can cause symptoms and signs that mimic mechanical bowel obstruction in patients. The symptoms depend on the parts of the gastrointestinal tract involved. Patients may have dysphagia with esoph ageal involvement, gastroparesis with stomach involve ment, intestinal pseudoobstruction with small bowel in volvement, or colonic pseudoobstruction with colonic involvement. Patients often have involvement of more than one part of the gastrointestinal tract. Gastrointesti nal motility abnormality can be the result of diseases that cause either smooth muscle or myenteric plexus abnormalities and dysfunction. It is important to locate the dysfunctional segment of the bowel so that proper treatment can be initiated. The incidence of severe gas trointestinal motility disturbance is not known, but it is probably more common than has been recognized. Me chanical obstruction of the bowel is much more com mon than pseudoobstruction; therefore, it must be ruled out before a diagnosis of pseudoobstruction is made. Gastrointestinal contents are moved along the di gestive tract as a result of normal coordinated pro pulsion of its wall. Abnormal gastrointestinal motil ity from either hypoactivity or uncoordinated hyperactivity causes ineffective propulsion and re tention of the contents in the defective organ. Ob structive symptoms of the defective organ will de velop in patients with severe gastrointestinal motility disturbance. Table 1 lists these manifesta tions. They may occur individually or in combi nation, depending on the diseases that cause the abnormal motility. In this review we discuss pathophysiology, causes, clinical manifestations, diagnosis, and treatment of these problems.
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Affiliation(s)
- Sinn Anuras
- Department of Internal Medicine, Texas Tech University Health Sciences Center; and Lubbock General Hospital, Lubbock, TX
| | - Jitra Anuras
- Department of Internal Medicine, Texas Tech University Health Sciences Center; and Lubbock General Hospital, Lubbock, TX
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Blondon H, Polivka M, Joly F, Flourie B, Mikol J, Messing B. Digestive smooth muscle mitochondrial myopathy in patients with mitochondrial-neuro-gastro-intestinal encephalomyopathy (MNGIE). ACTA ACUST UNITED AC 2005; 29:773-8. [PMID: 16294144 DOI: 10.1016/s0399-8320(05)86346-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We report 3 new cases of Mitochondrial-Neuro-Gastro-Intestinal Encephalomyopathy (MNGIE) (or Pseudo-Obstruction-Leukoencephalopathy-Intestinal-Pseudoobstruction Syndrome [POLIP]), a rare disease that associates chronic intestinal pseudo-obstruction (CIPO) and neurological symptoms. A review of the 72 reported cases together with these 3 cases revealed that this condition was associated with (a) a specific cluster of neurological symptoms including leukoencephalopathy (96%), polyneuropathy (96%), ophthalmoplegia (91%) and hearing loss (55%); (b) a CIPO syndrome with the presence of small bowel diverticulae (53%); and (c) mitochondrial cytopathy in 36 of the 37 tested patients (2 of our 3 cases), and thymidine phosphorylase gene mutations in all the 37 tested patients (2 of our cases). The etiology of POLIP/MNGIE syndrome appears therefore to be due to a mitochondrial cytopathy secondary to thymidine phosphorylase gene mutation(s). In 3 cases, including 2 of our 3 patients, mitochondrial abnormalities were evidenced at the ultrastructural level in digestive smooth muscle demonstrating that the pathogenesis of gastrointestinal involvement was directly related to mitochondrial alterations in digestive smooth muscle cells.
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Affiliation(s)
- Hugues Blondon
- Service d'Hépato-gastroentérologie et d'Assistance Nutritive, Hôpital Lariboisière, 75475 Paris Cedex 10
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Haftel LT, Lev D, Barash V, Gutman A, Bujanover Y, Lerman-Sagie T. Familial mitochondrial intestinal pseudo-obstruction and neurogenic bladder. J Child Neurol 2000; 15:386-9. [PMID: 10868781 DOI: 10.1177/088307380001500606] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intestinal dysmotility and neurogenic bladder have been described as part of two autosomal-recessive mitochondrial disorders assumed to be due to a defect in communication between the nuclear and mitochondrial genomes: myoneurogastrointestinal encephalopathy (MNGIE) and diabetes insipidus, diabetes mellitus, optic atrophy, and deafness (Wolfram syndrome). Partial cytochrome c oxidase deficiency has been described in both. We describe three Ashkenazi Jewish siblings with progressive intestinal dysmotility, neurogenic bladder, and autonomic manifestations but no central nervous system involvement. Cytochrome c oxidase deficiency was demonstrated in peripheral and multiple intestinal muscle biopsies. Mitochondrial DNA analysis of an intestinal biopsy of patient 1 showed heteroplasmy consisting of a normal 16.5-kb band and an approximately 28-kb band, suggestive of a duplication. Mitochondrial DNA analysis of a muscle biopsy of patient 2 showed multiple deletions, mainly 10- and 11-kb bands. We suggest that this unique combination of intestinal pseudo-obstruction and neurogenic bladder could comprise a new autosomal-recessive mitochondrial disorder.
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Affiliation(s)
- L T Haftel
- Pediatrics Department, Wolfson Medical Center, Holon, Israel
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7
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Abstract
Although the mtDNA encodes only 13 polypeptide subunits of the OXPHOS enzymes, approximately 1,000 proteins are estimated to be necessary for proper OXPHOS function. Over the past 10 years a wide variety of adult and pediatric OXPHOS diseases were found to be caused by or associated with mitochondrial DNA (mtDNA) mutations and nuclear DNA mutations. These advances enhanced the ability to definitively diagnose patients, develop management plans, and provide genetic counseling. Recently described nuclear DNA and mtDNA mutations are enhancing our understanding of this complex group of diseases. The impact of these advances on our understanding of OXPHOS disease pathogenesis will be reviewed.
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Affiliation(s)
- J M Shoffner
- Molecular Medicine Laboratory, Children's Healthcare of Atlanta, Georgia 30342, USA
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Abstract
Oxidative phosphorylation (OXPHOS) accounts for approximately 95% of the adenosine triphosphate (ATP) produced by the cell. The central nervous system, peripheral nervous system, cardiac muscle, skeletal muscle, and smooth muscle are highly susceptible to dysfunction of this complex enzyme system. Although most OXPHOS diseases are multisystem disorders, the neuromuscular manifestations are often prominent and play an important role in patient diagnosis. To assist the neurologist in evaluating these complex patients, this article focuses on selected samples of OXPHOS diseases with identifiable neuromuscular abnormalities and presents an evaluation algorithm to facilitate patient diagnosis.
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Affiliation(s)
- J M Shoffner
- Molecular Medicine Laboratory, Children's Healthcare of Atlanta, GA 30342, USA.
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Mueller LA, Camilleri M, Emslie-Smith AM. Mitochondrial neurogastrointestinal encephalomyopathy: manometric and diagnostic features. Gastroenterology 1999; 116:959-63. [PMID: 10092319 DOI: 10.1016/s0016-5085(99)70080-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- L A Mueller
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Guzé CD, Hyman PE, Payne VJ. Family studies of infantile visceral myopathy: a congenital myopathic pseudo-obstruction syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS 1999; 82:114-22. [PMID: 9934973 DOI: 10.1002/(sici)1096-8628(19990115)82:2<114::aid-ajmg3>3.0.co;2-h] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We conducted family studies of a rare congenital myopathic pseudo-obstruction to provide recurrence risks to families of affected children. This infantile visceral myopathy (IVM) involves the smooth muscles of the digestive tract and frequently the urinary bladder. Family and pregnancy histories from 16 families were evaluated to identify possible environmental or genetic components. The families were ethnically and geographically diverse within the United States. Eleven of the children were alive, four had died, and the status of one was unknown. The sex ratio was 5 females to 11 males. The pregnancy histories provided no evidence of a teratogenic cause. In one family, the disorder passed from parent to child. There were no consanguineous matings, no similarly affected sibs, and except for one case, the family histories did not suggest affected relatives. We suspect a new dominant mutation may be responsible for some cases of IVM, whereas in others, IVM may be caused from a dominant gene with variable expressivity and incomplete penetrance. Therefore, we predict the recurrence risk of severely affected children is much less than the 25 or 50% risk sometimes given families based on the assumption of autosomal recessive or autosomal dominant inheritance. When counseling IVM families, a thorough family history is essential. Subsequent pregnancies should be monitored by ultrasound for megacystis that was detected prenatally in seven of these cases.
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Affiliation(s)
- C D Guzé
- Department of Biology, California State University Dominguez Hills, Carson 90747, USA
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11
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Verma A, Piccoli DA, Bonilla E, Berry GT, DiMauro S, Moraes CT. A novel mitochondrial G8313A mutation associated with prominent initial gastrointestinal symptoms and progressive encephaloneuropathy. Pediatr Res 1997; 42:448-54. [PMID: 9380435 DOI: 10.1203/00006450-199710000-00005] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We describe a childhood mitochondrial disorder in which the clinical symptoms began and remained confined to the gastrointestinal (GI) system during the first 4 y. Seizures heralded the onset of progressive encephalopathy at age 7. Peripheral neuropathy, retinitis pigmentosa, and neural deafness developed subsequently. Laboratory investigations disclosed elevated levels of plasma lactate, and a muscle biopsy revealed ragged red fibers lacking cytochrome c oxidase activity and diminished levels of respiratory chain enzyme complexes. Molecular genetic tests failed to show any of the previously reported pathogenic mitochondrial DNA (mtDNA) mutations. We therefore screened the whole mitochondrial genome by coupling restriction digestions with single-strand conformational polymorphism (SSCP) patterns. We identified a unique SSCP in the segment that encompassed the tRNA(Lys) gene, and direct sequencing of this segment revealed a G-->A transition at an evolutionarily conserved nucleotide at mtDNA position 8313. This G8313A transition was heteroplasmic in muscle and fibroblasts of the patient, but was absent in the white blood cells and platelets from his maternal relatives. This report illustrates how GI symptoms can be the initial manifestation in a mitochondrial disorder and suggests that mitochondrial dysfunction should be considered in differentials of unexplained chronic GI symptoms, especially when lactic acidosis or other unrelated clinical signs or symptoms are present.
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Affiliation(s)
- A Verma
- Department of Neurology, University of Miami School of Medicine, Florida 33136, USA
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Abstract
Clinical or sub-clinical impairment of central and peripheral myelin is often part of the overlapping multisystem disorders associated with a variety of mitochondrial (mt)DNA abnormalities. Suboptimal energy metabolism of the oligodendrocytes and Schwann cells carrying mitochondrial defects may cause insufficient production of myelin. Further, edema, vascular and toxic factors may directly damage myelin. The recognition that certain mtDNA point mutations are associated with inflammatory demyelination of the central nervous system suggests that additional mechanisms besides degeneration need to be considered in the development of some forms of myelin damage.
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Affiliation(s)
- B Kalman
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA
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Rudolph CD, Hyman PE, Altschuler SM, Christensen J, Colletti RB, Cucchiara S, Di Lorenzo C, Flores AF, Hillemeier AC, McCallum RW, Vanderhoof JA. Diagnosis and treatment of chronic intestinal pseudo-obstruction in children: report of consensus workshop. J Pediatr Gastroenterol Nutr 1997; 24:102-12. [PMID: 9093995 DOI: 10.1097/00005176-199701000-00021] [Citation(s) in RCA: 138] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- C D Rudolph
- Children's Center for Motility Disorders, University of Cincinnati, Ohio, USA
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Li V, Hostein J, Romero NB, Marsac C, Mezin P, Bost R, Degoul F, Fardeau M, Fournet J. Chronic intestinal pseudoobstruction with myopathy and ophthalmoplegia. A muscular biochemical study of a mitochondrial disorder. Dig Dis Sci 1992; 37:456-63. [PMID: 1735370 DOI: 10.1007/bf01307743] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The association of chronic intestinal pseudoobstruction with ophthalmoplegia has been reported previously in visceral myopathies. We report a case of this association in which muscle mitochondria had a crystalline appearance, a dense core, and decreased cytochrome c oxidase and succinate cytochrome c reductase activities. The absence of evident mitochondrial DNA deletion in the skeletal muscle of this patient does not exclude the possibility of localized deletion or mutation of mitochondrial DNA in digestive muscle.
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Affiliation(s)
- V Li
- Service de Gastroentérologie et d'Hépatologie, Hopital A. Michallon, Grenoble, France
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Jones SC, Dixon MF, Lintott DJ, Axon AT. Familial visceral myopathy. A family with involvement of four generations. Dig Dis Sci 1992; 37:464-9. [PMID: 1735371 DOI: 10.1007/bf01307744] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A family with the autosomal dominant form of familial visceral myopathy is described involving four generations. The members illustrate several different clinical presentations including severe constipation, diarrhea, alternating constipation and diarrhea, volvulus, urinary tract infection, and retention of urine. One patient's history suggested that the uterus may have been involved. Diagnosis of this rare disease requires an awareness of the variable presentation and a careful histological examination of full-thickness sections of bowel. The potential pitfalls in both histological and clinical diagnosis of this condition are demonstrated in this family's history. The extensive involvement of small and large bowel in at least two family members is unusual in the autosomal dominant form of the disease, but their course has so far been favorable, lending further evidence to the impression that prognosis is good. This is of importance for genetic counseling of families who have this very rare disease.
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Affiliation(s)
- S C Jones
- Gastroenterology Unit, University Department of Pathology, Leeds General Infirmary, UK
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Abstract
Gastrointestinal motility is the function of gastrointestinal smooth muscle. It is controlled by both the intrinsic and extrinsic nerves of the gastrointestinal tract and, to a lesser degree, the gastrointestinal hormones. Therefore, any abnormality of the above factors, theoretically, can cause gastrointestinal dysmotility. In a clinical situation, commonly seen is gastrointestinal dysmotility caused by either smooth muscle or intrinsic and extrinsic nerves dysfunction. Diseases that cause smooth muscle dysfunction include familial visceral myopathies, nonfamilial visceral myopathies, collagen disease, muscular dystrophies, amyloidosis, thyroid disease, and so on. Diseases that cause enteric nerve dysfunction include familial visceral neuropathies, nonfamilial visceral neuropathies, diabetes mellitus, Chagas' disease, ganglioneuromatosis of the intestine, visceral neuropathy of carcinomatosis, Parkinson's disease, and so on. The patients with neuromuscular disease of the gastrointestinal tract have a wide range of clinical manifestations regardless of the underlying cause. At one end of the spectrum, the patients may be asymptomatic, and at the other end of the spectrum, the patients may have functional obstruction of the gastrointestinal tract. Plain abdominal x-rays, upper gastrointestinal (UGI) and small bowel x-rays, enteroclysis, barium enema, and manometric studies are useful for the work-up of these patients. Enteroclysis is especially helpful in ruling out mechanical obstruction of the small intestine in patients with chronic intestinal pseudo-obstruction. Treatment is mainly symptomatic and supportive. There is no effective drug to improve gastrointestinal motility. Surgery may be helpful in selected cases of severe gastrointestinal dysmotility.
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Schröder JM, Weber R, Weyhenmeyer S, Lammers-Reissing A, Meurers B, Reichmann H. Adult onset lipid storage in gastric mucosa and skeletal muscle fibers associated with gastric pain, progressive muscle weakness and partial deficiency of cytochrome C oxidase. Pathol Res Pract 1991; 187:85-95. [PMID: 1851299 DOI: 10.1016/s0344-0338(11)81050-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We report on the first case, a 21-year-old man, with partial deficiency of cytochrome c oxidase, lipid storage myopathy and concomitant lipid storage in the gastric mucosa affecting chief, parietal, and argentaffine cells as well as interstitial macrophages. The clinical symptoms consisted of increasing muscle weakness, cramps of the legs, and severe gastric pain that was resistant to treatment. Muscle biopsy specimens showed severe lipid storage in muscle fibers. Enzyme histochemistry revealed partial deficiency of cytochrome c oxidase (COX) with scattered non-reactive fibers among a majority of COX-positive fibers whereas biochemical analysis of muscle homogenates resulted in no corresponding defect of mitochondrial enzymes. Gastric biopsy specimens showed similarly to muscle fibers an extensive accumulation of lipid droplets in the chief cells, HCl producing parietal cells, macrophages, neutrophilic and eosinophilic leucocytes, and to a lesser degree also in argentaffine cells and unmyelinated axons of the gastric mucosa. The lipid droplets were associated with an insignificant increase in the number and size of mitochondria although paracristalline mitochondrial inclusions were neither noted in muscle fibers nor in cells of the gastric mucosa. These findings resemble those in multisystem triglyceride storage disease although the clinical signs were not reminiscent of this disease, and indicate that among the clinically heterogeneous group of cytochrome c oxidase deficiencies lipid storage may not be confined to muscle, but can affect the gastric mucosa as well.
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Affiliation(s)
- J M Schröder
- Institut für Neuropathologie, Medizinische Fakultät, RWTH Aachen, FRG
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18
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Simon LT, Horoupian DS, Dorfman LJ, Marks M, Herrick MK, Wasserstein P, Smith ME. Polyneuropathy, ophthalmoplegia, leukoencephalopathy, and intestinal pseudo-obstruction: POLIP syndrome. Ann Neurol 1990; 28:349-60. [PMID: 2173474 DOI: 10.1002/ana.410280308] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We describe 5 individuals (from three separate families) with a progressive neurological disorder characterized by sensorimotor peripheral polyneuropathy, cranial neuropathies (external ophthalmoplegia, deafness), and the syndrome of chronic intestinal pseudo-obstruction. Magnetic resonance imaging showed widespread abnormality of the cerebral and cerebellar white matter in the 2 patients studied. Autopsy examination in 3 revealed widespread endoneurial fibrosis and demyelination in the peripheral nervous system, possibly secondary to axonal atrophy, and poorly defined changes in cerebral white matter (leukoencephalopathy). The cranial nerves and spinal roots were less severely involved and the neurons in the brainstem and spinal cord were intact. The fatal gastrointestinal dysmotility was due to a severe visceral neuropathy. We suggest that these patients manifested a hereditary disorder with distinctive clinical, radiological, and neuropathological features, and propose the acronym POLIP to emphasize the distinctive tetrad of polyneuropathy, ophthalmoplegia, leukoencephalopathy, and intestinal pseudo-obstruction.
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Affiliation(s)
- L T Simon
- Department of Neurology, Stanford University School of Medicine, CA
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19
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Abstract
Neurologic diseases can affect the bowel at several levels of innervation--by altering the electrical activity that controls smooth muscle, the enteric nervous system, or the extrinsic neural pathways to the gut. This review concentrates on disorders of motility that occur in conjunction with diseases of the extrinsic neural supply (from the level of the brain to the postganglionic fibers) and those generalized disorders that affect gut smooth muscle. Modern technology, such as gastrointestinal scintigraphy and manometric techniques that measure esophageal, gastroduodenal, and anorectal motility (intraluminal pressures), has provided better methods to study the pathophysiologic aspects of gut motility in diseases of the nervous system. Distinguishing the neuropathies of the extrinsic nervous system from those of the intrinsic (enteric) nervous system is not always possible because the available techniques evaluate only the end-organ--that is, the motor function of the gut. Degenerative or infiltrative (myopathic) disorders of gut smooth muscle, however, can be distinguished from such neuropathies, and careful and systematic evaluation of autonomic function can often identify the level of disordered function in the neural-gut axis.
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Affiliation(s)
- M Camilleri
- Gastroenterology Research Unit, Mayo Clinic, Rochester, MN 55905
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Rodrigues CA, Shepherd NA, Lennard-Jones JE, Hawley PR, Thompson HH. Familial visceral myopathy: a family with at least six involved members. Gut 1989; 30:1285-92. [PMID: 2806997 PMCID: PMC1434252 DOI: 10.1136/gut.30.9.1285] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A family with at least six members affected by hollow organ visceral myopathy is described. Patients in the first or second decades of life developed symptoms which included weight loss, nausea and vomiting, abdominal pain and distension, constipation and diarrhoea, and urinary symptoms. The radiological features of the disease consisted of oesophageal aperistalsis, megaduodenum, and variable dilatation of the small and large bowel. Four patients had urinary tract involvement with dilatation of the ureters and/or incomplete bladder emptying. Two patients were severely affected and needed home parenteral nutrition and surgical treatment; others were symptomatic but remained well. The characteristic pathological abnormality was vacuolar degeneration predominantly affecting the longitudinal muscle. The disease in this family appears to be transmitted by autosomal dominant mode of inheritance.
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22
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Alstead EM, Murphy MN, Flanagan AM, Bishop AE, Hodgson HJ. Familial autonomic visceral myopathy with degeneration of muscularis mucosae. J Clin Pathol 1988; 41:424-9. [PMID: 3366929 PMCID: PMC1141469 DOI: 10.1136/jcp.41.4.424] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
An extended family with chronic intestinal pseudo-obstruction which affected 11 of 54 members was studied. Patients presented with recurrent intestinal obstruction in childhood or adolescence: eight of the 11 died before the age of 30. Pedigree analysis showed four consanguineous marriages. The patients were all in the fifth generation and had established an autosomal recessive mode of inheritance. Histological, immunocytochemical, and electron microscopic studies were performed on a colectomy specimen from a surviving affected family member. Familial visceral myopathy was diagnosed--characterised by degeneration and collagenous replacement of both layers of the muscularis propria and the muscularis mucosae.
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Affiliation(s)
- E M Alstead
- Department of Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, London
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23
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Abstract
A variety of pathological abnormalities of the smooth muscle and myenteric plexus result in clinical syndromes of disordered small intestinal and colonic motility. These pathological abnormalities have been noted by conventional light microscopy and by utilization of Smith's technique for visualizing the myenteric plexus with silver. We have classified the neuromuscular disorders into two major categories, i.e., those affecting the myenteric plexus and those affecting the smooth muscle. The classification is further developed based on the variety of clinicopathological features of the various disorders. Although we can now identify the underlying pathology of these motor disorders and thus understand these illnesses better than we did a decade ago, we have much more to learn. With the great strides being made to understand the normal structure, function, and development of the myenteric plexus and smooth muscle, there is hope that we will be able to learn much more about the etiology and pathogenesis of these neuromuscular disorders in the decade to come.
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Bardosi A, Creutzfeldt W, DiMauro S, Felgenhauer K, Friede RL, Goebel HH, Kohlschütter A, Mayer G, Rahlf G, Servidei S. Myo-, neuro-, gastrointestinal encephalopathy (MNGIE syndrome) due to partial deficiency of cytochrome-c-oxidase. A new mitochondrial multisystem disorder. Acta Neuropathol 1987; 74:248-58. [PMID: 2823522 DOI: 10.1007/bf00688189] [Citation(s) in RCA: 102] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A 42-year-old woman had a 10-year history of external ophthalmoplegia, malabsorption resulting in chronic malnutrition, muscle atrophy and polyneuropathy. Computer tomography revealed hypodensity of her cerebral white matter. A metabolic disturbance consisted of lactic acidosis after moderate glucose loads with increased excretion of hydroxybutyric and fumaric acids. Post-mortem studies revealed gastrointestinal scleroderma as the morphological manifestation of her malabsorption syndrome, ocular and skeletal myopathy with ragged red fibers, peripheral neuropathy, vascular abnormalities of meningeal and peripheral nerve vessels. Biochemical examination of the liver and muscle tissues revealed a partial defect of cytochrome-c-oxidase (complex IV of the respiratory chain). This mitochondrial multisystem disorder may represent a separate entity to be classified between the spectrum of myoencephalopathies and oculo-gastrointestinal muscular dystrophy.
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Affiliation(s)
- A Bardosi
- Abteilungen Neuropathologie, Universität Göttingen, Federal Republic of Germany
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Anuras S, Mitros FA, Milano A, Kuminsky R, Decanio R, Green JB. A familial visceral myopathy with dilatation of the entire gastrointestinal tract. Gastroenterology 1986; 90:385-90. [PMID: 3940913 DOI: 10.1016/0016-5085(86)90937-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We are reporting a new kindred in which familial visceral myopathy was identified in four siblings. There was no other symptomatic case identified in this 75-member, four-generation family, suggesting an autosomal recessive inheritance. All patients had recurrent symptoms of intestinal obstruction, and 3 died from malnutrition. Gastrointestinal lesions showed marked dilatation of the entire digestive tract from the esophagus to the rectum, which is different from other types of familial visceral myopathies. Microscopic examination of the gastrointestinal smooth muscle showed degeneration and increased fibrosis indistinguishable from other types of familial visceral myopathy.
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