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Wang Y, Zhang E, Ye C, Wu B. Refractory Hypotension in a Late-Onset Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like Episodes (MELAS) Male with m.3243 A>G Mutation: A Case Report. Brain Sci 2023; 13:1080. [PMID: 37509011 PMCID: PMC10377322 DOI: 10.3390/brainsci13071080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Introduction: Symptom spectrum can be of great diversity and heterogeneity in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) patients in clinical practice. Here, we report a case of MELAS presenting asymptomatic refractory hypotension with m.3243 A>G mutation. (2) Case representation: A 51-year-old male patient presented with a headache, vertigo, and difficulty in expression and understanding. The magnetic resonance imaging of the brain revealed an acute stroke-like lesion involving the left temporoparietal lobe. A definitive diagnosis of MELAS was given after the genetic test identified the chrM-3243 A>G mutation. The patient suffered recurrent stroke-like episodes in the 1-year follow-up. Notably, refractory hypotension was observed during hospitalizations, and no significant improvement in blood pressure was found after continuous use of vasopressor drugs and fluid infusion therapy. (3) Conclusions: We report a case of refractory hypotension which was unresponsive to fluid infusion therapy found in a patient with MELAS. Our case suggests that comprehensive management should be paid attention to during treatment. A further study on the pathological mechanism of the multisystem symptoms in MELAS would be beneficial to the treatment of patients.
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Affiliation(s)
- Youjie Wang
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Enhui Zhang
- Department of Neurology, West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu 610041, China
| | - Chen Ye
- Department of Neurology, West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu 610041, China
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Solis A, Shimony J, Shinawi M, Barton KT. Case report: malignant hypertension associated with catecholamine excess in a patient with Leigh syndrome. Clin Hypertens 2023; 29:7. [PMID: 36855210 PMCID: PMC9976414 DOI: 10.1186/s40885-022-00231-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 11/15/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Leigh syndrome is a progressive neurodegenerative mitochondrial disorder caused by multiple genetic etiologies with multisystemic involvement that mostly affecting the central nervous system with high rate of premature mortality. CASE PRESENTATION We present a 3-year, 10 month-old female patient with Leigh syndrome complicated by renal tubular acidosis, hypertension, gross motor delay, who presented with hypertensive emergency, persistent tachycardia, insomnia and irritability. Her previous genetic workup revealed a pathogenic variant in the MT-ND5 gene designated as m.13513G > A;p.Asp393Asn with a heteroplasmy of 69%. She presented acutely with malignant hypertension requiring intensive care unit admission. Her acute evaluation revealed elevated serum and urine catecholamines, without an identifiable catecholamine-secreting tumor. After extensive evaluation for secondary causes, she was ultimately found to have progression of her disease with new infarctions in her medulla, pons, and basal ganglia as the most likely etiology of her hypertension. She was discharged home with clonidine, amlodipine and atenolol for hypertension management. This report highlights the need to recognize possible autonomic dysfunction in mitochondrial disease and illustrates the challenges for accurate and prompt diagnosis and subsequent management of the associated manifestations. This association between catecholamine induced autonomic dysfunction and Leigh syndrome has been previously reported only once with MT-ND5 mutation. CONCLUSIONS Elevated catecholamines with malignant secondary hypertension may be unique to this specific mutation or may be a previously unrecognized feature of Leigh syndrome and other mitochondrial complex I deficient syndromes. As such, patients with Leigh syndrome who present with malignant hypertension should be treated without the need for extensive work-up for catecholamine-secreting tumors.
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Affiliation(s)
- Ana Solis
- grid.4367.60000 0001 2355 7002Department of Pediatrics, Washington University in St Louis School of Medicine, 660 S. Euclid Ave, St Louis, MO 63110 USA
| | - Joshua Shimony
- grid.4367.60000 0001 2355 7002Mallinkrodt Institute of Radiology, Washington University in St Louis School of Medicine, 4525 Scott Avenue Campus, Box 8131, St Louis, MO 63141 USA
| | - Marwan Shinawi
- grid.4367.60000 0001 2355 7002Department of Pediatrics, Washington University in St Louis School of Medicine, 660 S. Euclid Ave, St Louis, MO 63110 USA
| | - Kevin T. Barton
- grid.4367.60000 0001 2355 7002Department of Pediatrics, Washington University in St Louis School of Medicine, 660 S. Euclid Ave, St Louis, MO 63110 USA
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Kucherov V, Truong H, Raab C, Hagerty JA. Urologic presentations and management options in pediatric mitochondrial disease. Urology 2022; 164:230-237. [PMID: 35016974 DOI: 10.1016/j.urology.2021.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/27/2021] [Accepted: 12/26/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To review the evaluation and management of urologic pathology related to mitochondiral diseases (MD) in childhood. METHODS A retrospective review was performed of patients with MD from 1/1/2000 - 10/8/2020 who were referred for urologic evaluation at a single childrens hospital. Clinical and demographic information was reviewed including symptomatology, urodynamic evaluation, and medical/surgical management. RESULTS 15 patients were identified for inclusion. Median age of presentation was 5 years and median follow up was 4 years. Patients presented with numerous urologic complaints including urinary retention/incomplete emptying, incontinence, and recurrent urinary tract infection. Urodynamics demonstrated elevated median bladder capacity at 172% of expected as calculated by age. Detrusor sphincter dyssynergia (DSD) was present in 6 (50%). Progression to surgical intervention occurred in 67% at a median time of 3.5 years after initial referral. This included suprapubic tube (SPT) placement and sacral neuromodulation (SNM). CONCLUSIONS Patients in this study were found to have a spectrum of lower urinary tract dysfunction (LUTD) with elevated bladder capacity being common. No singular urodynamic feature prevailed although DSD was found in 50%. Progression of symptoms over time was also common. Most patients (67%) did go on to surgical intervention including SPT and SNM. Clinicians should be aware of the possibility of LUTD in children with MD and they should be promptly referred to pediatric urology when LUTD is suspected.
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Affiliation(s)
- Victor Kucherov
- Department of Urology, Thomas Jefferson University Hospital, 1025 Walnut Street, Suite 1100, Philadelphia, PA 19107.
| | - Hong Truong
- Department of Urology, Thomas Jefferson University Hospital, 1025 Walnut Street, Suite 1100, Philadelphia, PA 19107.
| | - Christopher Raab
- Division of Diagnostic Referral, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803.
| | - Jennifer A Hagerty
- Division of Pediatric Urology, Department of Surgery, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803.
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4
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Feeney C, Gorman G, Stefanetti R, McFarland R, Turnbull D, Harding C, Sachdeva A. Lower urinary tract dysfunction in adult patients with mitochondrial disease. Neurourol Urodyn 2020; 39:2253-2263. [PMID: 32969525 DOI: 10.1002/nau.24479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/29/2020] [Indexed: 12/11/2022]
Abstract
AIMS Mitochondrial diseases present with a spectrum of clinical features, usually with multiorgan involvement and are often characterized by a loss of smooth muscle function. Hence, we hypothesized that mitochondrial dysfunction may contribute to lower urinary tract (LUT) dysfunction. METHODS We performed a prospective cohort study at a single, quaternary, mitochondrial disease referral center, enrolling consecutive adult patients with genetically confirmed mitochondrial disease. Data regarding baseline characteristics and disease burden were gathered. LUT dysfunction was assessed using the International Consultation on Incontinence Modular Questionnaire-Lower Urinary Tract Symptoms (ICIQ-LUTS) questionnaire, bladder voiding efficiency (BVE), and bladder diaries. Patients with one or more features of LUT dysfunction were offered urodynamic testing. RESULTS A total of 109 patients were included. Twenty-six percent of patients manifested at least one feature of LUT dysfunction, which was objectively confirmed in all 14 patients who consented to urodynamic investigation. Disease burden, defined by the Newcastle Mitochondrial Disease Adult Scale (NMDAS), demonstrated a linear relationship with ICIQ-LUTS severity (P = .01), with a statistically significant relationship between NMDAS-gastrointestinal scores and LUTS scores (P < .001). Limitations include mutational heterogeneity across the patient cohort. CONCLUSIONS This is the largest study exploring LUT in patients with mitochondrial disease and supports previous smaller studies suggesting LUT dysfunction is underrecognized in patients with mitochondrial disease and impacts considerably on their quality of life. We propose a clinical guideline for identifying mitochondrial disease patients at risk of LUT dysfunction.
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Affiliation(s)
- Catherine Feeney
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
- Department of Neurology, Royal Victoria Infirmary, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Grainne Gorman
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
- Department of Neurology, Royal Victoria Infirmary, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Renae Stefanetti
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
| | - Robert McFarland
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
- Department of Neurology, Royal Victoria Infirmary, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Doug Turnbull
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
- Department of Neurology, Royal Victoria Infirmary, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Christopher Harding
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ashwin Sachdeva
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle upon Tyne, UK
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
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5
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Rose S, Niyazov DM, Rossignol DA, Goldenthal M, Kahler SG, Frye RE. Clinical and Molecular Characteristics of Mitochondrial Dysfunction in Autism Spectrum Disorder. Mol Diagn Ther 2018; 22:571-593. [PMID: 30039193 PMCID: PMC6132446 DOI: 10.1007/s40291-018-0352-x] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Autism spectrum disorder (ASD) affects ~ 2% of children in the United States. The etiology of ASD likely involves environmental factors triggering physiological abnormalities in genetically sensitive individuals. One of these major physiological abnormalities is mitochondrial dysfunction, which may affect a significant subset of children with ASD. Here we systematically review the literature on human studies of mitochondrial dysfunction related to ASD. Clinical aspects of mitochondrial dysfunction in ASD include unusual neurodevelopmental regression, especially if triggered by an inflammatory event, gastrointestinal symptoms, seizures, motor delays, fatigue and lethargy. Traditional biomarkers of mitochondrial disease are widely reported to be abnormal in ASD, but appear non-specific. Newer biomarkers include buccal cell enzymology, biomarkers of fatty acid metabolism, non-mitochondrial enzyme function, apoptosis markers and mitochondrial antibodies. Many genetic abnormalities are associated with mitochondrial dysfunction in ASD, including chromosomal abnormalities, mitochondrial DNA mutations and large-scale deletions, and mutations in both mitochondrial and non-mitochondrial nuclear genes. Mitochondrial dysfunction has been described in immune and buccal cells, fibroblasts, muscle and gastrointestinal tissue and the brains of individuals with ASD. Several environmental factors, including toxicants, microbiome metabolites and an oxidized microenvironment are shown to modulate mitochondrial function in ASD tissues. Investigations of treatments for mitochondrial dysfunction in ASD are promising but preliminary. The etiology of mitochondrial dysfunction and how to define it in ASD is currently unclear. However, preliminary evidence suggests that the mitochondria may be a fruitful target for treatment and prevention of ASD. Further research is needed to better understand the role of mitochondrial dysfunction in the pathophysiology of ASD.
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Affiliation(s)
- Shannon Rose
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Dmitriy M Niyazov
- Section of Medical Genetics, Ochsner Health System, New Orleans, LA, USA
| | | | - Michael Goldenthal
- Department of Pediatrics, Neurology Section, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Stephen G Kahler
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Richard E Frye
- Division of Neurodevelopmental Disorders, Department of Neurology, Barrow Neurological Institute, Phoenix Children's Hospital, 1919 E Thomas St, Phoenix, AZ, USA.
- Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA.
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6
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Leigh Syndrome Caused by the MT-ND5 m.13513G>A Mutation: A Case Presenting with WPW-Like Conduction Defect, Cardiomyopathy, Hypertension and Hyponatraemia. JIMD Rep 2015; 19:95-100. [PMID: 25681084 DOI: 10.1007/8904_2014_375] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 09/19/2014] [Accepted: 10/15/2014] [Indexed: 04/05/2023] Open
Abstract
Mitochondrial disease can present with a wide range of clinical phenotypes, and knowledge of the clinical spectrum of mitochondrial DNA mutation is constantly expanding. Leigh syndrome (LS) has been reported to be caused by the m.13513G>A mutation in the ND5 subunit of complex I (MT-ND5 m.13513G>A). We present a case of a 12-month-old infant initially diagnosed with tachyarrhythmia requiring defibrillation, subsequent presentation with hypertension and hyponatraemia secondary to renal salt loss and presumed inappropriate ADH secretion. Complex I activity in the muscle tissue was 54%, and mutation load in the muscle and lymphocytes was 50%. This case of Leigh syndrome caused by the m.13513G>A mutation in the ND5 gene illustrates that hyponatraemia due to renal sodium loss and inappropriate ADH secretion and hypertension can be features of this entity in addition to the previously reported cardiomyopathy and WPW-like conduction pattern and that they present additional challenges in diagnosis and management.
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Chaussenot A, Paquis-Flucklinger V. An overview of neurological and neuromuscular signs in mitochondrial diseases. Rev Neurol (Paris) 2014; 170:323-38. [DOI: 10.1016/j.neurol.2014.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 03/24/2014] [Indexed: 01/10/2023]
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8
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Chou PC, Liang WC, Nonaka I, Mitsuhashi S, Nishino I, Jong YJ. Intranuclear rods myopathy with autonomic dysfunction. Brain Dev 2013; 35:686-9. [PMID: 23102861 DOI: 10.1016/j.braindev.2012.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 09/22/2012] [Accepted: 09/25/2012] [Indexed: 10/27/2022]
Abstract
Intranuclear rods myopathy (IRM), a variant of nemaline myopathy (NM), is characterized by rod structure in the myonuclei. Patients with IRM present with similar symptoms to those of severe infantile-type NM but have worse outcome. Several extramuscular manifestations have been reported in NM but no dysautonomia. We herein report a 2-year-old girl with IRM and a heterozygous mutation, c.430C>T (p.L144F) in ACTA1. During the infancy, the patient showed severe diaphoresis and facial flushing. Arrhythmia and hypertension with the precipitating factors of feeding, defecation, and urination were observed. Sympathetic antagonist was prescribed and showed some effectiveness. Our report may widen the clinical spectrum of IRM. It also reminds clinicians that autonomic dysfunction may occur in patients with IRM or other actinopathies and appropriate treatment may be necessary.
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Affiliation(s)
- Po-Ching Chou
- Departments of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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9
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Scheibye-Knudsen M, Croteau DL, Bohr VA. Mitochondrial deficiency in Cockayne syndrome. Mech Ageing Dev 2013; 134:275-83. [PMID: 23435289 PMCID: PMC3663877 DOI: 10.1016/j.mad.2013.02.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 01/24/2013] [Accepted: 02/08/2013] [Indexed: 01/05/2023]
Abstract
Cockayne syndrome is a rare inherited disorder characterized by accelerated aging, cachectic dwarfism and many other features. Recent work has implicated mitochondrial dysfunction in the pathogenesis of this disease. This is particularly interesting since mitochondrial deficiencies are believed to be important in the aging process. In this review, we discuss recent findings of mitochondrial pathology in Cockayne syndrome and suggest possible mechanisms for the mitochondrial dysfunction.
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Affiliation(s)
| | - Deborah L. Croteau
- Laboratory of Molecular Gerontology, National Institute on Aging, NIH, USA
| | - Vilhelm A. Bohr
- Laboratory of Molecular Gerontology, National Institute on Aging, NIH, USA
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10
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Abstract
Genetic disorders affecting the autonomic nervous system can result in abnormal development of the nervous system or they can be caused by neurotransmitter imbalance, an ion-channel disturbance or by storage of deleterious material. The symptoms indicating autonomic dysfunction, however, will depend upon whether the genetic lesion has disrupted peripheral or central autonomic centers or both. Because the autonomic nervous system is pervasive and affects every organ system in the body, autonomic dysfunction will result in impaired homeostasis and symptoms will vary. The possibility of genetic confirmation by molecular testing for specific diagnosis is increasing but treatments tend to remain only supportive and directed toward particular symptoms.
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11
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Abstract
The autonomic nervous system is involved and influenced in patients with epilepsy and mitochondrial diseases in a variety of complex, often multifaceted, mechanisms. Autonomic dysfunction often remains unrecognized due to a lack of attention and awareness under the prominence of other disease symptoms. Recognition of the diverse autonomic manifestations of epilepsy and mitochondrial disease would enhance early diagnosis and appropriate management, ultimately improving quality the of life and reducing morbidity and mortality in the affected patients. In this chapter, we discuss autonomic nervous system dysfunction in children with epilepsy (Part I) and mitochondrial diseases (Part II).
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Affiliation(s)
- Sumit Parikh
- Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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12
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Kanjwal K, Karabin B, Kanjwal Y, Saeed B, Grubb BP. Autonomic dysfunction presenting as orthostatic intolerance in patients suffering from mitochondrial cytopathy. Clin Cardiol 2011; 33:626-629. [PMID: 20960537 DOI: 10.1002/clc.20805] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Disturbances in autonomic nervous system function have been reported to occur in patients suffering from mitochondrial cytopathies. However, there is paucity of literature on the occurrence of orthostatic intolerance (OI) in these patients. We report on a series of patients diagnosed with mitochondrial cytopathy who developed features of autonomic dysfunction in the form of OI. METHODS This was a single-center report on a series of 6 patients who were followed in our clinic for orthostatic intolerance. All of these patients had a diagnosis of mitochondrial cytopathy on the basis of muscle biopsy and were being followed at a center specializing in the treatment of mitochondrial disorders. This study was approved by our local institutional review board. Each of the patients had suffered from symptoms of fatigue, palpitations, near syncope, and syncope. The diagnosis of OI was confirmed by head-up tilt test. Collected data included demographic information, presenting symptoms, laboratory data, tilt-table response, and treatment outcomes. RESULTS Six patients (3 females) were identified for inclusion in this report. The mean age of the group was 48 ± 8 years (range, 40-60 years). All of these patients underwent head-up tilt table testing and all had a positive response that reproduced their clinical symptoms. Among those having an abnormal tilt-table pattern, 1 had a neurocardiogenic response, 1 had a dysautonomic response, and 4 had a postural orthostatic tachycardia response. All but 1 patient reported marked symptom relief with pharmacotherapy. The patient who failed pharmacotherapy received a dual-chamber closed-loop pacemaker and subsequently reported marked improvement in her symptoms with elimination of her syncope. CONCLUSIONS Orthostatic intolerance might be a significant feature of autonomic nervous system dysfunction in patients suffering from mitochondrial cytopathy.
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Affiliation(s)
- Khalil Kanjwal
- Section of Electrophysiology, Division of Cardiology, Division of Internal Medicine
| | - Beverly Karabin
- Section of Electrophysiology, Division of Cardiology, Division of Internal Medicine
| | - Yousuf Kanjwal
- Section of Electrophysiology, Division of Cardiology, Division of Internal Medicine
| | - Bilal Saeed
- Department of Medicine, The University of Toledo Medical Center, Toledo, Ohio
| | - Blair P Grubb
- Section of Electrophysiology, Division of Cardiology, Division of Internal Medicine
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Parsons T, Weimer L, Engelstad K, Linker A, Battista V, Wei Y, Hirano M, Dimauro S, De Vivo DC, Kaufmann P. Autonomic symptoms in carriers of the m.3243A>G mitochondrial DNA mutation. ACTA ACUST UNITED AC 2010; 67:976-9. [PMID: 20697048 DOI: 10.1001/archneurol.2010.174] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The m.3243A>G mutation can cause multisystem medical problems and can affect the autonomic nervous system. OBJECTIVE To study the frequency and spectrum of autonomic symptoms associated with the m.3243A>G mitochondrial DNA point mutation. Design, Setting, and Patients We studied a cohort of 88 matrilineal relatives from 40 families, including 35 fully symptomatic patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes (MELAS), 53 carrier relatives, and 16 controls using a questionnaire based on existing standard instruments for the evaluation of autonomic dysfunction. We compared the questionnaire with an expert evaluation. We compared data among the 3 groups using the Mantel-Haenszel chi(2) test to determine the statistical significance of differences between groups. RESULTS Mutation carriers frequently had symptoms of autonomic dysfunction, specifically gastrointestinal and orthostatic intolerance. CONCLUSIONS Carriers of the m.3243A>G mutation have frequent autonomic symptoms. The m.3243A>G mutation should be considered as an etiological factor in patients with autonomic dysfunction and a medical or family history suggestive of mitochondrial disease. Because some autonomic symptoms are treatable, early detection and proactive management may mitigate the burden of morbidity.
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Affiliation(s)
- Timothy Parsons
- Department of Neurology, Columbia University, 710 W 168th St, New York, NY 10032, USA
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14
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Di Leo R, Musumeci O, de Gregorio C, Recupero A, Grimaldi P, Messina C, Coglitore S, Vita G, Toscano A. Evidence of cardiovascular autonomic impairment in mitochondrial disorders. J Neurol 2007; 254:1498-503. [PMID: 17987253 DOI: 10.1007/s00415-007-0536-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Revised: 10/01/2006] [Accepted: 01/17/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate autonomic nervous system (ANS) function in mitochondrial disorders (MD). BACKGROUND MD are characterized by a wide range of clinical features, including heart abnormalities and peripheral and central nervous systems involvement. Rarely autonomic symptoms have been reported. METHODS 22 patients with MD underwent a battery of cardiovascular reflex tests including five tests of parasympathetic function and four tests of sympathetic function. Power spectral analyses (PSA) of heart rate variability in the supine and upright positions were also evaluated. Plasma levels of adrenaline, noradrenaline and dopamine were determined in the standing and lying positions. RESULTS Only 4/22 patients referred symptoms related to ANS dysfunction. 46% of patients had a definite autonomic damage (i. e. an autonomic score >/= 4). 36% showed moderate alterations with an autonomic score in the range 2-3 and 18 % had a normal autonomic function. MD patients had a significantly (p <0.03) lower increase of adrenaline level after standing. CONCLUSIONS Our data indicate an autonomic dysfunction in more than 80% of MD patients, even in the absence of a clinically manifested autonomic involvement. Cardiovascular autonomic investigation might be systematically employed in the characterization of MD.
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Affiliation(s)
- Rita Di Leo
- Department of Neurosciences Psychiatry and Anaesthesiology, University of Messina, Via Consolare Valeria 98125, Messina, Italy
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15
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Abstract
The scope of pediatric autonomic disorders is not well recognized. The goal of this review is to increase awareness of the expanding spectrum of pediatric autonomic disorders by providing an overview of the autonomic nervous system, including the roles of its various components and its pervasive influence, as well as its intimate relationship with sensory function. To illustrate further the breadth and complexities of autonomic dysfunction, some pediatric disorders are described, concentrating on those that present at birth or appear in early childhood.
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Affiliation(s)
- Felicia B Axelrod
- Dysautonomia Treatment and Evaluation Center, Department of Pediatrics and Neurology, New York University School of Medicine, 530 First Ave, Suite 9Q, New York, New York 10016, USA.
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Hirano M, Nishigaki Y, Martí R. Mitochondrial Neurogastrointestinal Encephalomyopathy (MNGIE): A Disease of Two Genomes. Neurologist 2004; 10:8-17. [PMID: 14720311 DOI: 10.1097/01.nrl.0000106919.06469.04] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mitochondrial encephalomyopathies are clinically and genetically heterogeneous because mitochondria are the products of 2 genomes: mitochondrial DNA (mtDNA) and nuclear DNA (nDNA). Among the mendelian-inherited mitochondrial diseases are defects of intergenomic communication, disorders due to nDNA mutations that cause depletion and multiple deletions of mtDNA. REVIEW SUMMARY Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an autosomal recessive disorder of intergenomic communication and is defined clinically by 1) severe gastrointestinal dysmotility; 2) cachexia; 3) ptosis, ophthalmoparesis, or both; 4) peripheral neuropathy; and 5) leukoencephalopathy. Skeletal muscle biopsies of patients have revealed abnormalities of mtDNA and mitochondrial respiratory chain enzymes. The disease is caused by mutations in the thymidine phosphorylase (TP) gene. TP protein catalyzes phosphorolysis of thymidine to thymine and deoxyribose 1-phosphate. In MNGIE patients, TP enzyme activity is reduced drastically, and plasma thymidine and deoxyuridine are elevated dramatically. We have hypothesized that alterations of nucleoside metabolism cause an imbalanced mitochondrial nucleotide pool that leads to depletion and deletions of mtDNA. CONCLUSIONS MNGIE is a recognizable clinical syndrome caused by mutations in TP. The diagnosis can be confirmed by measuring TP activity in buffy coat or plasma levels of thymidine and deoxyuridine. Reduction of circulating thymidine and deoxyuridine in MNGIE patients may be therapeutic.
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Affiliation(s)
- Michio Hirano
- Department of Neurology, Columbia University College of Physicians & Surgeons, New York, NY, USA.
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Boles RG, Adams K, Ito M, Li BUK. Maternal inheritance in cyclic vomiting syndrome with neuromuscular disease. Am J Med Genet A 2003; 120A:474-82. [PMID: 12884425 DOI: 10.1002/ajmg.a.20126] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Cyclic vomiting syndrome (CVS), characterized by severe discrete episodes of nausea, vomiting, and lethargy, is a predominately childhood condition associated with migraine and dysautonomic features. Disease-associated mitochondrial DNA (mtDNA) sequence variants are suggested by a strong maternal bias in the inheritance of migraine, and the recent findings of mtDNA variants in a few children with CVS and additional neuromuscular disease manifestations ("CVS+"). A clinical interview using a questionnaire was administered (generally) to one parent of 62 children with CVS+. Non-senile disease manifestations, including migraine, myopathy, seizures, and dysautonomia-like symptoms, were far more common in matrilineal versus non-matrilineal relatives, including being present in 75% of the mothers versus in only 11% of the fathers (P < 0.001). Overall, maternal inheritance is suggested in 86% of the families (in 65% strongly so). Disease manifestations in subjects and their affected matrilineal relatives are predominately intermittent and consistent with dysautonomia, including increased vital sign fluctuations. Body fluid metabolites and muscle biopsy findings are consistent with mitochondrial dysfunction in most cases tested. We conclude that mtDNA sequence variants are at least risk factors in the development of disease in most children at this "severe" end of the CVS spectrum, likely involving a maternally inherited propensity towards dysautonomia.
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Affiliation(s)
- Richard G Boles
- Division of Medical Genetics, Childrens Hospital Los Angeles, Los Angeles, California 90027, USA.
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Momiyama Y, Suzuki Y, Ohtomo M, Atsumi Y, Matsuoka K, Ohsuzu F, Kimura M. Cardiac autonomic nervous dysfunction in diabetic patients with a mitochondrial DNA mutation: assessment by heart rate variability. Diabetes Care 2002; 25:2308-13. [PMID: 12453978 DOI: 10.2337/diacare.25.12.2308] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To elucidate the degree and characteristics of cardiac autonomic nervous dysfunction in diabetic patients associated with a mitochondrial DNA mutation at base pair 3243. RESEARCH DESIGN AND METHODS We investigated heart rate variability using 24-h Holter monitoring in 10 diabetic patients with the mutation compared with 55 ordinary diabetic patients and 45 nondiabetic control subjects. RESULTS Age and sex were similar in the three groups. Between patients with the mutation and ordinary diabetic patients, the duration of diabetes and blood glycemic levels were not different. In the time domain analysis of heart rate variability, patients with the mutation and ordinary diabetic patients had significantly smaller SDNN index and pNN50 than control subjects. Compared with ordinary diabetic patients, patients with the mutation had smaller SDNN index (P < 0.02), but rMSSD and pNN50 were not different. In the frequency domain analysis, total, low frequency (LF), and high frequency (HF) spectra were significantly smaller in patients with the mutation and ordinary diabetic patients than in control subjects. Compared with ordinary diabetic patients, patients with the mutation had smaller total and LF spectra (P < 0.02). However, HF spectra were not significantly different. Notably, the LF/HF spectra ratio was lower in patients with the mutation than in ordinary diabetic patients and control subjects (P < 0.05), but this ratio was similar in ordinary diabetic patients and control subjects. CONCLUSIONS Our results suggest that diabetic patients with the mitochondrial DNA mutation have more severely impaired cardiac autonomic nervous function with sympathovagal imbalance, as compared with ordinary diabetic patients.
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Affiliation(s)
- Yukihiko Momiyama
- First Department of Internal Medicine, National Defense Medical College, Saitama, Japan.
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Abstract
Mitochondrial dysfunction should be considered in the differential diagnosis of any progressive multisystem disorder. The diagnosis is most challenging when only one symptom is present. In contrast, the diagnosis is easier to consider when two or more seemingly unrelated symptoms are present, involving more than one organ system. It is important to consider the diagnosis of a mitochondrial disorder when dealing with an unexplained association of symptoms, with an early onset and progressive course involving seemingly unrelated organs. The investigation can be relatively straightforward if a person has a recognizable phenotype and if it is possible to identify a known pathogenic mtDNA mutation. The difficulty arises when no known mtDNA defect can be found or when the clinical abnormalities are complex and not easily matched to those of more common mitochondrial disorders. In summary: A full mitochondrial evaluation often is warranted in children with a complex neurologic picture or a single neurologic symptom and other system involvement. When the presentation is classic for a maternally inherited mitochondrial syndrome, such as MELAS, MERRF, or Leber's hereditary optic neuropathy, appropriate mtDNA studies should be obtained first. When the clinical picture is classic for a nuclear DNA inherited syndrome and the gene or linkage is known, such as MNGIE, the clinician should proceed with genetic studies. When the clinical picture is nonspecific but highly suggestive of a mitochondrial disorder, the clinician should start with plasma or CSF lactic acid, ketone bodies, plasma acylcarnitines, and urinary organic acids. If these studies are abnormal, the clinician should proceed with muscle biopsy and assessment of the respiratory chain enzymes. Normal plasma or CSF lactic acid does not rule out a mitochondrial disorder.
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Affiliation(s)
- Lynette Gillis
- Section of Biochemical Genetics, Department of Human Genetics and Molecular Biology, Division of Gastroenterology and Nutrition, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Abstract
Mitochondrial diseases are a heterogeneous group of disorders with widely varying clinical features, due to defects in mitochondrial function. Involvement of both muscle and nerve is common in mitochondrial disease. In some cases, this involvement is subclinical or a minor part of a multisystem disorder, but myopathy and neuropathy are a major, often presenting, feature of a number of mitochondrial syndromes. In addition, mitochondrial dysfunction may play a role in a number of classic neuromuscular diseases. This article reviews the role of mitochondrial dysfunction in neuromuscular disease and discusses a rational approach to diagnosis and treatment of patients presenting with a neuromuscular syndrome due to mitochondrial disease.
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Affiliation(s)
- R A Nardin
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard Institute of Medicine, Rm 858, 77 Avenue Louis Pasteur, Boston, Massachusetts 02115, USA
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Nishino I, Spinazzola A, Papadimitriou A, Hammans S, Steiner I, Hahn CD, Connolly AM, Verloes A, Guimar�es J, Maillard I, Hamano H, Donati MA, Semrad CE, Russell JA, Andreu AL, Hadjigeorgiou GM, Vu TH, Tadesse S, Nygaard TG, Nonaka I, Hirano I, Bonilla E, Rowland LP, DiMauro S, Hirano M. Mitochondrial neurogastrointestinal encephalomyopathy: An autosomal recessive disorder due to thymidine phosphorylase mutations. Ann Neurol 2001. [DOI: 10.1002/1531-8249(200006)47:6<792::aid-ana12>3.0.co;2-y] [Citation(s) in RCA: 242] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Nissenkorn A, Zeharia A, Lev D, Watemberg N, Fattal-Valevski A, Barash V, Gutman A, Harel S, Lerman-Sagie T. Neurologic presentations of mitochondrial disorders. J Child Neurol 2000; 15:44-8. [PMID: 10641610 DOI: 10.1177/088307380001500110] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This article describes the neurologic presentations of children with mitochondrial disorders. The charts of 42 children with highly suspect mitochondrial disorders were reviewed. Thirty-seven children were diagnosed as having definite mitochondrial disorders based on a suggestive clinical presentation and at least one accepted criteria, while in five patients the diagnosis remained probable. All patients had nervous system involvement, but it was the presenting symptom in 28 of 42. Eighteen children had normal intelligence and 24 had mental retardation or developmental delay at the onset of their disease. Twenty-five patients had either an acute regression or a progressive encephalopathy. The most frequent neurologic manifestations were abnormal tone, seizures, extrapyramidal movements, and autonomic dysfunction. The eyes were involved in 11 children. Nerve deafness was found in seven patients. Myopathy was found in only six patients. In conclusion, a complex neurologic picture, especially with other organ involvement, warrants a full mitochondrial evaluation.
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Affiliation(s)
- A Nissenkorn
- Pediatric Neurology Unit and Metabolic-Neurogenetic Clinic, Wolfson Medical Center, Holon, Israel
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