Spinal and bulbar muscular atrophy: androgen receptor dysfunction caused by a trinucleotide repeat expansion

X-Linked Spinal Muscular Atrophy 2 due to a Synonymous Variant in the UBA1 Gene in a Family with Novel Findings from Turkey

Spinal muscular atrophy, X-linked 2 (SMAX2) is a rare type of spinal muscular atrophy characterized by muscle weakness, hypotonia, areflexia, myopathic face, tongue fibrillations, contractures, bone fractures, and cryptorchidism. Variants of the UBA1 gene lead to SMAX2. The UBA1 gene encodes a protein that activates the ubiquitin pathway which is responsible for protein degradation. Here, we describe a family presenting with hypotonia, muscle weakness, areflexia, contractures, weak cry, in association with other anomalies including myopathic face, scoliosis, tongue fibrillations, and cryptorchidism. Molecular analysis in 2 patients revealed a hemizygous pathogenic variant in the UBA1 gene (NM_153280.3, NP_695012.1: c.1731C>T [p.Asn577Asn]) inherited from their carrier mothers. Our study presents the first patients from Turkey, widening the phenotypic spectrum of SMAX2 by pectus carinatum, medullary sponge kidney, and frontal cyst.

Diagnostic Challenge and Neuromuscular Junction Contribution to ALS Pathogenesis

Amyotrophic lateral sclerosis (ALS) represents the major adult-onset motor neuron disease. Both human and animal studies reveal the critical implication of muscle and neuromuscular junctions (NMJs) in the initial phase of this disease. Despite the common efforts, ALS diagnosis remains particularly challenging since many other disorders can overlap yielding similar clinical phenotypic features. A combination of further research on the NMJ parameters that are specific for this disease and laboratory tests are crucial for the early determination of specific changes in the muscle, as well as in motor neuron and the prediction of ALS progression. Also, it could provide a powerful tool in the discrimination of particular ALS and ALS-mimic cases and increase the efficacy of therapeutic treatments.

Cancer incidence in patients with polyglutamine diseases: a population-based study in Sweden

BACKGROUND

Polyglutamine (polyQ) diseases are characterised by the expansion of CAG triplet repeats in specific genes. The accumulated encoded proteins affect the transcription of numerous transcription factors. We investigated whether polyQ diseases reduce the risk of cancer development.

METHODS

Data on patients with the polyQ diseases Huntington's disease (HD), spinobulbar muscular atrophy (SBMA), and hereditary ataxia (HA) in Sweden were linked to the Swedish Cancer Registry. We calculated standardised incidence ratios for cancers at specific sites or of specific types and the risks were compared with those in the general population. We also analysed risks in the unaffected parents of patients.

FINDINGS

In the period January, 1969, to December, 2008, we identified 1510 patients with HD, 471 with SBMA, and 3425 with HA. Cancer was diagnosed in 91 (6·0%) HD patients, 34 (7·2%) SBMA patients, and 421 (12·3%) HA patients. The standardised incidence ratios were 0·47 (95% CI 0·38-0·58), 0·65 (0·45-0·91), and 0·77 (0·70-0·85), respectively. Before diagnosis of polyQ disease, the risk of cancer was even lower. Cancer incidence and risk in the unaffected parents of patients with polyQ diseases were similar to those in the general population.

INTERPRETATION

The consistently decreased incidence of cancer in patients with polyQ diseases suggests that a common mechanism protects against the development of cancer. This feature could be related to the polyQ-tract expansion seen in these diseases. Further studies are warranted to investigate the underlying mechanisms linking cancer and polyQ diseases.

FUNDING

Swedish Cancer Society, Swedish Council for Working Life and Social Research.

Complications after cardiovascular surgery in a case of undiagnosed spinal-bulbar muscular atrophy (Kennedy disease)

Neurodegenerative diseases are often associated with life-threatening declines in respiratory and swallowing mechanisms. We report the case of a 70-year-old man who had postoperative dysphagia and respiratory failure that required reintubation after coronary artery bypass surgery. Impairment of the patient's speech, swallowing, and respiratory mechanisms identified during postoperative clinical and instrumental examinations was suggestive of a neurodegenerative disease. Genetic testing confirmed a diagnosis of spinal-bulbar muscular atrophy (Kennedy disease). This case report aims to highlight increased morbidity in patients with undiagnosed neuromuscular disorders in the critical care setting and the benefits of vigilant postoperative monitoring and multidisciplinary involvement throughout the care of complex patients.

Are cognitive and behavioural deficits a part of the clinical picture in Kennedy's disease? A case study

Two years prior to diagnosis of Kennedy's disease (KD), a 53-year-old man began experiencing neurological symptoms, including nasal speech, postural tremor, tremor in the upper extremities, and muscle weakness. Genetic analysis revealed 46 CAG repeats in the androgen receptor gene. The patient's altered social conduct and complaints of forgetfulness led to a neuropsychological assessment. A mild impairment in visuospatial and visuoconstructive abilities, visual short-term memory, and a personality disorder were detected. Although cognition and behaviour in KD are typically normal, our findings suggest that the disease may cause mild cognitive and behavioural changes as part of the disease's clinical manifestation.

Androgen receptor gene CAG repeat length as a modifier of the association between persistent organohalogen pollutant exposure markers and semen characteristics

OBJECTIVES

Exposure to persistent organohalogen pollutants was suggested to impair male reproductive function. A gene-environment interaction has been proposed. No genes modifying the effect of persistent organohalogen pollutants on reproductive organs have yet been identified. We aimed to investigate whether the CAG and GGN polymorphisms in the androgen receptor gene modify the effect of persistent organohalogen pollutant exposure on human sperm characteristics.

METHODS

Semen and blood from 680 men [mean (SD) age 34 (10) years] from Greenland, Sweden, Warsaw (Poland) and Kharkiv (Ukraine) were collected. Persistent organohalogen pollutant exposure was assessed by measuring serum levels of 2,2',4,4',5,5'-hexachlorobiphenyl (CB-153) and dichlorodiphenyl dichloroethene (p,p'-DDE). Semen characteristics (volume, sperm concentration, total count, proportion of progressively motile and morphology) and DNA fragmentation index (DFI) were determined. CAG and GGN repeat lengths were determined by direct sequencing of leukocyte DNA.

RESULTS

A statistically significant interaction was found between the CB-153 group and CAG repeat category in relation to sperm concentration and total sperm count (P=0.03 and 0.01, respectively). For p,p'-DDE, in the European cohorts a significant interaction was found in relation to DFI (P=0.01). For CAG<20, sperm concentration and total sperm count were 35 and 42% lower, respectively, when the group with CB-153 exposure above median was compared with that below the median. DFI was 40% higher in the high p,p'-DDE exposure group for CAG<or=21.

CONCLUSIONS

This study indicated that the androgen receptor CAG repeat length might modify the susceptibility of an individual to the adverse effects of persistent organohalogen pollutant exposure on semen quality. Other studies regarding this matter are warranted.

Real-time PCR analysis of trinucleotide repeat allele expansions in the androgen receptor gene

INTRODUCTION

The expansion of specific trinucleotide repeats results in certain genetic disorders.

METHOD

Real-time PCR analysis was used to rapidly discriminate between normal and expanded (CAG)(n) alleles in the androgen receptor gene.

RESULT

The difference in melting temperature (T(m)) between the most common normal and expanded alleles was approximately 1 degrees C.

CONCLUSION

Real-time PCR analysis seems to be a highly reliable and rapid method, which may facilitate the first molecular approach to human trinucleotide repeat disorders.

Dementia of frontal lobe type in Kennedy's disease

The pathomorphological correlate of Kennedy's disease (KD) is a degeneration of spinal and bulbar alpha-motor neurons. The disease is caused by a CAG repeat expansion in the first exon of the X-chromosomal androgene receptor gene. Contrary to the common belief that cognitive disorders in motor neuron diseases (MND) are either rare or only mild, there is now an increasing number of case reports on dementia in amyotrophic lateral sclerosis (ALS). In ALS, dementia of the frontal lobe type (frontotemporal dementia, FTD) seems to be the characteristic pattern. However, in KD cognitive dysfunction has not been studied systematically. Here we present a case with clinical characteristics of FTD in a patient with genetically confirmed KD. It remains speculative whether there is an association between KD and FTD comparable to a genetic linkage between ALS and FTD, which has been proposed in recent years. However, we suggest that cognitive dysfunction may be more common in KD than reported until today.

Clinical and electrophysiological features in Chinese patients with Kennedy’s disease

Kennedy's disease is a X-linked neuromuscular disorder caused by an expanded trinucleotide repeat in the androgen receptor gene. To ascertain the clinical diagnosis of Kennedy's disease in a Chinese population, we used a rapid, accurate PCR-based sizing method for the CAG repeat allelotype. The clinical and electrophysiological features of affected patients are described. The CAG repeats ranged from 43 to 53 and were inversely correlated with the age of onset (r = -0.63; P < 0.005).

The cellular and molecular pathology of the motor system in hereditary spastic paraparesis due to mutation of the spastin gene

Hereditary spastic paraparesis (HSP) is a genetically heterogeneous disorder, the most common cause of which is mutation of the spastin gene. Recent evidence suggests a role for spastin in microtubule dynamics, but the distribution of the protein within the CNS is unknown. The core neuropathology of HSP is distal degeneration of the lateral corticospinal tract and of fasciculus gracilis, but there are few neuropathological studies of cases with a defined mutation. We aimed to determine the distribution of spastin expression in the human CNS and to investigate the cellular pathology of the motor system in HSP due to mutation of the spastin gene. Using an antibody to spastin, we have carried out immunohistochemistry on postmortem brain. We have demonstrated that spastin is a neuronal protein. It is widely expressed in the CNS so that the selectivity of the degeneration in HSP is not due to the normal cellular distribution of the protein. We have identified mutation of the spastin gene in 3 autopsy cases of HSP. Distal degeneration of long tracts in the spinal cord, consistent with a dying back axonopathy, was accompanied by a microglial reaction. The presence of novel hyaline inclusions in anterior horn cells and an alteration in immunostaining for cytoskeletal proteins and mitochondria indicates that long tract degeneration is accompanied by cytopathology in the motor system and may support a role for derangement of cytoskeletal function. All 3 cases also demonstrated evidence of tau pathology outside the motor system, suggesting that the neuropathology is not confined to the motor system in spastin-related HSP.

Developmental mechanisms in the pathogenesis of neurodegenerative diseases

Cellular genes that are mutated in neurodegenerative diseases code for proteins that are expressed throughout neural development. Genetic analysis suggests that these genes are essential for a broad range of normal neurodevelopmental processes. The proteins they code for interact with numerous other cellular proteins that are components of signaling pathways involved in patterning of the neural tube and in regional specification of neuronal subtypes. Further, pathogenetic mutations of these genes can cause progressive, sublethal alterations in the cellular homeostasis of evolving regional neuronal subpopulations, culminating in late-onset cell death. Therefore, as a consequence of the disease mutations, targeted cell populations may retain molecular traces of abnormal interactions with disease-associated proteins by exhibiting changes in a spectrum of normal cellular functions and enhanced vulnerability to a host of environmental stressors. These observations suggest that the normal functions of these disease-associated proteins are to ensure the fidelity and integration of developmental events associated with the progressive elaboration of neuronal subtypes as well as the maintenance of mature neuronal populations during adult life. The ability to identify alterations within vulnerable neuronal precursors present in pre-symptomatic individuals prior to the onset of irrevocable cellular injury may help foster the development of effective therapeutic interventions using evolving pharmacologic, gene and stem cell technologies.

BDNF regulation of androgen receptor expression in axotomized SNB motoneurons of adult male rats

Brain-derived neurotrophic factor (BDNF) prevents the axotomy-induced loss of androgen receptor-like immunoreactivity (AR-LI) in the spinal nucleus of the bulbocavernosus (SNB) motoneurons of adult male rats. In this report, we investigated the dose-response effect of BDNF on androgen receptor expression in axotomized SNB motoneurons, and examined whether delayed application of BDNF to the cut SNB axons can completely reverse the axotomy-induced loss of androgen receptor expression. We also used autoradiography to test whether axotomy decreases the ability of SNB motoneurons to accumulate androgens. SNB motoneurons were axotomized bilaterally and BDNF or PBS was applied to the proximal ends of the axons. The percentage of SNB motoneurons expressing medium or high AR-LI was the major measure of androgen receptor expression. AR-LI was significantly higher on the BDNF-treated side than on the contralateral side treated with phosphate-buffered saline (PBS) for all three doses of BDNF (1.45, 2.9, and 5.8 mg/ml) and was higher than in rats treated bilaterally with PBS. Moreover, AR-LI at the highest dose of BDNF was not different from that in intact SNB motoneurons. Delayed application of BDNF to the axotomized SNB motoneurons restored the AR-LI to the intact level. The AR-LI decreased by axotomy started to increase significantly 4 days after BDNF application and returned to the intact level by 10 days. Furthermore, axotomy significantly decreased the percentage of SNB motoneurons to accumulate tritiated testosterone or its metabolites. In conclusion, our data demonstrate that BDNF completely prevents and reverses the axotomy-induced loss of AR-LI. Moreover, decrease of AR-LI by axotomy reflects the decrease in the ability of SNB motoneurons to accumulate androgens.

Disassembly of nuclear inclusions in the dividing cell--a novel insight into neurodegeneration

Spinocerebellar ataxias and Huntington's disease are examples of neurodegenerative diseases caused by a trinucleotide repeat expansion. One hallmark of such diseases is the formation of inclusion bodies (IBs) within neuronal tissue. Although these inclusions may play a pivotal role in the disease process, the reasons underlying their specific accumulation remain obscure. By studying intranuclear IBs in dividing cells we demonstrate for the first time that inclusions such as those of ataxin-1 disperse during mitosis, thus reducing the nuclear aggregate burden. IBs reform in the interphase nucleus. By high-resolution confocal microscopy we also show that inclusions comprise ordered structures capable of homotypic interactions. Unlike those of a non-pathologic protein, ataxin-1 inclusions were shown to be capable of non-specific protein sequestration. Our studies indicate that the specific accumulation of inclusions in terminally differentiated cells such as neurons is a direct consequence of their inability to divide and therefore provides a key to explaining their persistence in neurodegenerative disease.

High prevalence of Kennedy's disease in Western Finland -- is the syndrome underdiagnosed?

OBJECTIVES

To assess the prevalence of Kennedy's disease in the Vasa region of Western Finland.

PATIENTS AND METHODS

Verification of diagnosis by molecular genetic techniques since 1995.

RESULTS

Within 2 years we have been able to identify a large number of families with this disorder. We have arrived at a point prevalence of Kennedy's disease in the district of Vasa Central Hospital of 13 patients per 85,000 male inhabitants. Assuming an even distribution throughout the country, this would suggest hundreds of patients with this disorder in Finland.

CONCLUSION

Kennedy's disease is the most common motor neuron disorder in the Vasa region, exceeding the prevalence of ALS by a factor of two, and far more common than any of the other motor neuron disorders. The fact that none of our patients, despite previous examinations, had correct diagnoses before 1995, indicates that Kennedy's disease still might be relatively underdiagnosed.

Androgen insensitivity syndrome in the era of molecular genetics and the Internet: a point of view

The era of molecular genetics has seen the discovery of a great deal of scientific information about the androgen receptor (AR) and about the many AR mutations that have been identified in patients with Androgen Insensitivity Syndrome (AIS). In families with well-characterised mutations, carriers can now be identified and prenatal testing can be offered. An unexpected finding is that an AR mutation also causes X-linked spinobulbar muscular atrophy. The intersex community has established two influential support groups, the AIS Support Group (which has branches in the UK, North America and Australia) and the Intersex Society of North America (ISNA). It is ironic that at a time when advances in biomedical science regarding AIS are a source of pride, these support groups are accusing the medical profession of having ignored the real needs of patients with AIS. Since the support groups are willing to assist the medical profession to develop better approaches to the management of intersex disorders, a collaborative approach is likely to be mutually beneficial for patients and physicians. ISNA has alienated many doctors by advocating a radical approach, namely that surgery should not be performed to 'correct' ambiguous genitalia until the individual is old enough to express a gender preference. Many children born in developing countries have either no genital surgery to correct ambiguity, or surgery is carried out very late. Long term outcome studies, carried out in developing countries and sensitive to the cultural background, would provide information on how non-Western societies can accept genital abnormalities that would be considered unacceptable in the West.

Nuclear receptors: structure, function and involvement in disease

Nuclear hormone receptors are acting as transcription factors in the cell nucleus. They regulate gene expression of hormonal regulated target genes. The role of hormone in the transcriptional process is to modulate and change the nuclear receptor functionality. Receptors contain a DNA binding domain that enables them to bind to hormone response elements of target genes. Nuclear hormone receptors bind to lipophilic hormones produced by the organisms' endocrine system, which links the secretion of hormones directly to regulation of gene expression of responsive tissues. In recent years increasing numbers of naturally occurring mutations of a variety of nuclear hormone receptor genes were identified in patients showing abnormalities in hormonal response. Here, we present an overview of nuclear receptors and their mutant forms which cause human syndromes or are associated with cancer progression. The major scope of this article is to give an overview on the structural-functional relationship and based on that, to understand the effects of naturally occurring receptor mutants on the molecular level. Thereby, functional aberrations of naturally occurring receptors for androgen, glucocorticoids, mineralocorticoid, estrogen, vitamin D3, retinoic acid, and thyroid hormone as well as the orphan receptor DAX1 are discussed.