Sarcomeric myopathies associated with tremor: new insights and perspectives

Type selective ablation of postnatal slow and fast fatigue-resistant motor neurons in mice induces late onset kinetic and postural tremor following fiber-type transition and myopathy

Animals on Earth need to hold postures and execute a series of movements under gravity and atmospheric pressure. VAChT-Cre is a transgenic Cre driver mouse line that expresses Cre recombinase selectively in motor neurons of S-type (slow-twitch fatigue-resistant) and FR-type (fast-twitch fatigue-resistant). Sequential motor unit recruitment is a fundamental principle for fine and smooth locomotion; smaller-diameter motor neurons (S-type, FR-type) first contract low-intensity oxidative type I and type IIa muscle fibers, and thereafter larger-diameter motor neurons (FInt-type, FF-type) are recruited to contract high-intensity glycolytic type IIx and type IIb muscle fibers. To selectively eliminate S- and FR-type motor neurons, VAChT-Cre mice were crossbred with NSE-DTA mice in which the cytotoxic diphtheria toxin A fragment (DTA) was expressed in Cre-expressing neurons. The VAChT-Cre;NSE-DTA mice were born normally but progressively manifested various characteristics, including body weight loss, kyphosis, kinetic and postural tremor, and muscular atrophy. The progressive kinetic and postural tremor was remarkable from around 20 weeks of age and aggravated. Muscular atrophy was apparent in slow muscles, but not in fast muscles. The increase in motor unit number estimation was detected by electromyography, reflecting compensatory re-innervation by remaining FInt- and FF-type motor neurons to the orphaned slow muscle fibers. The muscle fibers gradually manifested fast/slow hybrid phenotypes, and the remaining FInt-and FF-type motor neurons gradually disappeared. These results suggest selective ablation of S- and FR-type motor neurons induces progressive muscle fiber-type transition, exhaustion of remaining FInt- and FF-type motor neurons, and late-onset kinetic and postural tremor in mice.

A Case Series of Patients With MYBPC1 Gene Variants Featuring Undulating Tongue Movements as Myogenic Tremor

Myosin-binding protein C1 (MYBPC1) encodes myosin-binding protein C, slow type (sMyBP-C), an accessory protein that regulates actomyosin cross-linking, stabilizes thick filaments, and modulates contractility in muscle sarcomeres and has recently been linked to myopathy with tremor. The clinical features of MYBPC1 mutations manifesting in early childhood bear some similarities to those of spinal muscular atrophy (SMA), such as hypotonia, involuntary movement of the tongue and limbs, and delayed motor development. The development of novel therapies for SMA has necessitated the importance of differentiating SMA from other diseases in the early infancy period. We report the characteristic tongue movements of MYBPC1 mutations, along with other clinical findings, such as positive deep tendon reflexes and normal peripheral nerve conduction velocity testing, which could help in considering other diseases as differential diagnoses.

Electrophysiological Characterization of a MYH7 Variant with Tremor Phenotype

Background

The concept of a myopathy with associated tremor ("myogenic tremor") in humans has been previously described for specific MYBPC1 (Myosin-Binding Protein C) variants. Here we report for the first time an individual with tremor who was found to have a de-novo likely pathogenic variant in Myosin Heavy Chain 7 (MYH7).

We provide a detailed electrophysiological characterization of the tremor syndrome in a human individual with a myopathy and this pathogenic MYH7 variant to provide further insight in the phenotypic spectrum and pathomechanism of myogenic tremors in skeletal sarcomeric myopathies.

Methods

Electromyographic recordings were obtained from facial muscles, as well as bilateral upper and lower extremities.

Results

10 to 11 Hz activity was observed in the face and extremities during recordings with muscle activation. There were intermittent episodes of significant left-right coherence that would modulate across muscle groups throughout the recording, but no coherence between muscles at different levels of the neuraxis.

Conclusions

A possible explanation for this phenomenon is that the tremor originates at the sarcomere level within muscles, which is then picked up by muscle spindles and leads to activating input to the neuraxis segment. At the same time, the stability of the tremor frequency does suggest the presence of central oscillators at the segmental level. Thus, further studies will be needed to determine the origin of myogenic tremor and to better understand the pathomechanism.

A computational approach to quantitatively define sarcomere dimensions and arrangement in skeletal muscle

BACKGROUND AND OBJECTIVE

The skeletal muscle is composed of integrated tissues mainly composed of myofibers i.e., long, cylindrical syncytia, whose cytoplasm is mostly occupied by parallel myofibrils. In section, each myofibril is organized in serially end-to-end arranged sarcomeres connected by Z lines. In muscle disorders, these structural and functional units can undergo structural alterations in terms of Z-line and sarcomere lengths, as well as lateral alignment of Z-line among adjacent myofibrils. In this view, objectifying alterations of the myofibril and sarcomere architecture would provide a solid foundation for qualitative observations. In this work, specific quantitative parameters characterizing the sarcomere and myofibril arrangement were defined using a computerized analysis of ultrastructural images.

METHODS

computerized analysis was carried out on transmission electron microscopy pictures of the murine vastus lateralis muscle. Samples from both euploid (control) and trisomic (showing myofiber alterations) Ts65Dn mice were used. Two routines were written in MATLAB to measure specific structural parameters on sarcomeres and myofibrils. The output included the Z-line, M-line, and sarcomere lengths, the Aspect Ratio (AsR) and Curviness (Cur) sarcomere shape parameters, myofibril axis (α angle), and the H parameter (evaluation of sequence of Z-lines of adjacent myofibrils).

RESULTS

Both routines worked well in control (euploid) skeletal muscle yielding consistent quantitative data of sarcomere and myofibril structural organization. In comparison with euploid, trisomic muscle showed statistically significant lower Z-line length, similar M-line length, and statistically significant lower sarcomere length. Both AsR and Cur were statistically significantly lower in trisomic muscle, suggesting the sarcomere is barrel-shaped in the latter. The angle (α) distribution showed that the sarcomere axes are almost parallel in euploid muscle, while a large variability occurs in trisomic tissue. The mean value of H was significantly higher in trisomic versus euploid muscle indicating that Z-lines are not perfectly aligned in trisomic muscle.

CONCLUSIONS

Our procedure allowed us to accurately extract and quantify sarcomere and myofibril parameters from the high-resolution electron micrographs thereby yielding an effective tool to quantitatively define trisomy-associated muscle alterations. These results pave the way to future objective quantification of skeletal muscle changes in pathological conditions.

SHORT ABSTRACT

The skeletal muscle is composed of integrated tissues mainly composed of myofibers i.e., long, cylindrical syncytia, whose cytoplasm is mostly occupied by parallel myofibrils organized in serially end-to-end arranged sarcomeres. Several pieces of evidence have highlighted that in muscle disorders and diseases the sarcomere structure may be altered. Therefore, objectifying alterations of the myofibril and sarcomere architecture would provide a solid foundation for qualitative observations. A computerized analysis was carried out on transmission electron microscopy images of euploid (control) and trisomic (showing myofiber alterations) skeletal muscle. Two routines were written in MATLAB to measure nine sarcomere and myofibril structural parameters. Our computational method confirmed and expanded on previous qualitative ultrastructural findings defining several trisomy-associated skeletal muscle alterations. The proposed procedure is a potentially useful tool to quantitatively define skeletal muscle changes in pathological conditions involving the sarcomere.

Sarcomeric deficits underlie MYBPC1-associated myopathy with myogenic tremor

Myosin binding protein-C slow (sMyBP-C) comprises a subfamily of cytoskeletal proteins encoded by MYBPC1 that is expressed in skeletal muscles where it contributes to myosin thick filament stabilization and actomyosin cross-bridge regulation. Recently, our group described the causal association of dominant missense pathogenic variants in MYBPC1 with an early-onset myopathy characterized by generalized muscle weakness, hypotonia, dysmorphia, skeletal deformities, and myogenic tremor, occurring in the absence of neuropathy. To mechanistically interrogate the etiologies of this MYBPC1-associated myopathy in vivo, we generated a knock-in mouse model carrying the E248K pathogenic variant. Using a battery of phenotypic, behavioral, and physiological measurements spanning neonatal to young adult life, we found that heterozygous E248K mice faithfully recapitulated the onset and progression of generalized myopathy, tremor occurrence, and skeletal deformities seen in human carriers. Moreover, using a combination of biochemical, ultrastructural, and contractile assessments at the level of the tissue, cell, and myofilaments, we show that the loss-of-function phenotype observed in mutant muscles is primarily driven by disordered and misaligned sarcomeres containing fragmented and out-of-register internal membranes that result in reduced force production and tremor initiation. Collectively, our findings provide mechanistic insights underscoring the E248K-disease pathogenesis and offer a relevant preclinical model for therapeutic discovery.

Myogenic tremor - a novel tremor entity

PURPOSE OF REVIEW

Tremor is a common neurological symptom with a plethora of potential etiologies. Apart from physiological tremor, the vast majority of tremor syndromes are linked to a pacemaker in the central nervous system (CNS) or, less common, in the peripheral nervous system. Myogenic tremor is a novel tremor entity, first reported in 2019 and believed to originate in the muscle itself. In this review, we describe the clinical properties of myogenic tremor and discuss its presumed pathogenesis on the basis of all of the patient cases published so far.

RECENT FINDINGS

Myogenic tremor manifests itself as a high frequency, postural, and kinetic tremor with onset in infancy. To date, only myopathies affecting the contractile elements, in particular myosin and a myosin-associated protein, have been recognized to feature myogenic tremor. The generator of the tremor is believed to be located in the sarcomere, with propagation and amplification of sarcomeric oscillatory activity through CNS reflex loops, similar to neuropathic tremor.

SUMMARY

True myogenic tremor must be distinguished from centrally mediated tremor due to myopathies with central nervous system involvement, i.e., mitochondrial myopathies or myotonic dystrophies. The presence of myogenic tremor strongly points toward a sarcomere-associated mutation and may thus be a valuable clinical tool for the differential diagnosis of myopathies.