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El-Wahsh S, Morris K, Limaye S, Riminton S, Corbett A, Triplett JD. Hypogammaglobulinemia and infection risk in myotonic dystrophy type 1. Muscle Nerve 2024. [PMID: 39267217 DOI: 10.1002/mus.28247] [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: 08/26/2023] [Revised: 08/26/2024] [Accepted: 08/27/2024] [Indexed: 09/17/2024]
Abstract
INTRODUCTION/AIMS Hypogammaglobulinemia is a common yet under-recognized feature of myotonic dystrophy type 1 (DM1). The aims of our study were to determine the frequency of immunoglobulin G (IgG) deficiency in our cohort, to examine the association between immunoglobulin levels and cytosine-thymine-guanine (CTG) repeat length in the DMPK gene, and to assess whether IgG levels are associated with an increased risk of infection in DM1 patients. METHODS We conducted a single-center, retrospective cross-sectional study of 65 adult patients with DM1 who presented to the Neuromuscular Clinic at Concord Repatriation General Hospital, Sydney, Australia, between January 2002 and January 2022. We systematically collected and analyzed clinical, laboratory, and genetic data for all patients with available serum electrophoresis and/or IgG level results. RESULTS Forty-one percent of DM1 patients had IgG deficiency despite normal lymphocyte counts, IgA, IgM, and albumin levels. There was an association between CTG repeat expansion size and the degree of IgG deficiency (F = 6.3, p = .02). There was no association between IgG deficiency and frequency of infection in this group (p = .428). DISCUSSION IgG deficiency is a frequent occurrence in DM1 patients and is associated with CTG repeat expansion size. Whether hypogammaglobulinemia is associated with increased infection risk in DM1 is unclear. A prospective multicenter cohort study is needed to evaluate this.
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Affiliation(s)
- Shadi El-Wahsh
- Department of Neurology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Katrina Morris
- Department of Neurology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sandhya Limaye
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Clinical Immunology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Sean Riminton
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Clinical Immunology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Alastair Corbett
- Department of Neurology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - James D Triplett
- Department of Neurology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Finsterer J, Mehri S. Prevention of sudden death in Kearns-Sayre syndrome requires prospective studies. Pacing Clin Electrophysiol 2022; 45:1419-1420. [PMID: 36315646 DOI: 10.1111/pace.14614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sounira Mehri
- Biochemistry Laboratory, LR12ES05 "Nutrition-Functional Foods and Vascular Health", Faculty of Medicine, Monastir, Tunisia
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Nieuwenhuis S, Widomska J, Blom P, ‘t Hoen PBAC, van Engelen BGM, Glennon JC. Blood Transcriptome Profiling Links Immunity to Disease Severity in Myotonic Dystrophy Type 1 (DM1). Int J Mol Sci 2022; 23:3081. [PMID: 35328504 PMCID: PMC8954763 DOI: 10.3390/ijms23063081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/01/2022] [Accepted: 03/03/2022] [Indexed: 02/01/2023] Open
Abstract
The blood transcriptome was examined in relation to disease severity in type I myotonic dystrophy (DM1) patients who participated in the Observational Prolonged Trial In DM1 to Improve QoL- Standards (OPTIMISTIC) study. This sought to (a) ascertain if transcriptome changes were associated with increasing disease severity, as measured by the muscle impairment rating scale (MIRS), and (b) establish if these changes in mRNA expression and associated biological pathways were also observed in the Dystrophia Myotonica Biomarker Discovery Initiative (DMBDI) microarray dataset in blood (with equivalent MIRS/DMPK repeat length). The changes in gene expression were compared using a number of complementary pathways, gene ontology and upstream regulator analyses, which suggested that symptom severity in DM1 was linked to transcriptomic alterations in innate and adaptive immunity associated with muscle-wasting. Future studies should explore the role of immunity in DM1 in more detail to assess its relevance to DM1.
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Affiliation(s)
- Sylvia Nieuwenhuis
- Center for Molecular and Biomolecular Informatics (CMBI), Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands; (S.N.); (P.-B.A.C.‘t.H.)
- Department of Cognitive Neuroscience, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Centre, 6525 EN Nijmegen, The Netherlands;
| | - Joanna Widomska
- Department of Cognitive Neuroscience, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Centre, 6525 EN Nijmegen, The Netherlands;
| | - Paul Blom
- VDL Enabling Technologies Group B.V., 5651 GH Eindhoven, The Netherlands;
| | - Peter-Bram A. C. ‘t Hoen
- Center for Molecular and Biomolecular Informatics (CMBI), Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands; (S.N.); (P.-B.A.C.‘t.H.)
| | - Baziel G. M. van Engelen
- Department of Neurology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands;
| | - Jeffrey C. Glennon
- Department of Cognitive Neuroscience, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Centre, 6525 EN Nijmegen, The Netherlands;
- Conway Institute of Biomolecular and Biomedical Research, School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
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Farini A, Villa C, Tripodi L, Legato M, Torrente Y. Role of Immunoglobulins in Muscular Dystrophies and Inflammatory Myopathies. Front Immunol 2021; 12:666879. [PMID: 34335568 PMCID: PMC8316973 DOI: 10.3389/fimmu.2021.666879] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/25/2021] [Indexed: 01/15/2023] Open
Abstract
Muscular dystrophies and inflammatory myopathies are heterogeneous muscular disorders characterized by progressive muscle weakness and mass loss. Despite the high variability of etiology, inflammation and involvement of both innate and adaptive immune response are shared features. The best understood immune mechanisms involved in these pathologies include complement cascade activation, auto-antibodies directed against muscular proteins or de-novo expressed antigens in myofibers, MHC-I overexpression in myofibers, and lymphocytes-mediated cytotoxicity. Intravenous immunoglobulins (IVIGs) administration could represent a suitable immunomodulator with this respect. Here we focus on mechanisms of action of immunoglobulins in muscular dystrophies and inflammatory myopathies highlighting results of IVIGs from pre-clinical and case reports evidences.
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Affiliation(s)
- Andrea Farini
- Stem Cell Laboratory, Department of Pathophysiology and Transplantation, University of Milan, Dino Ferrari Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | | | - Yvan Torrente
- Stem Cell Laboratory, Department of Pathophysiology and Transplantation, University of Milan, Dino Ferrari Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
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5
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Implications of Fc Neonatal Receptor (FcRn) Manipulations for Transplant Immunotherapeutics. Transplantation 2020; 104:17-23. [PMID: 31397806 DOI: 10.1097/tp.0000000000002912] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alloimmune injury to allografts is mediated by pathogenic donor-specific alloantibodies, usually of the IgG isotype. Currently, strategies used to reduce donor-specific alloantibodies are collectively called desensitization. Despite successes, these treatments have limited efficacy and can be associated with adverse events, infectious complications, and high cost. Fc neonatal receptor (FcRn) was originally discovered as a transport mechanism for IgG from maternal circulation to fetus. FcRn receptors are now known to be widely distributed in virtually all tissues. IgG and albumin binding to FcRn is pH-dependent, which results in a significant prolongation their half-life. Structural analysis shows FcRn is a nonclassical major histocompatibility complex Class I receptor, which is emerging as a novel target to significantly reduce the half-life of pathogenic antibodies or extend the half-life of therapeutic monoclonals. Manipulation of IgG-Fc/FcRn interactions has implications for treatment of virtually all IgG-mediated diseases. The use of monoclonals directed at the FcRn can rapidly enhance the turnover of total IgG, including pathogenic IgG. In this review, we highlight the aspects of FcRn biology responsible for development of FcRn targeted therapeutics aimed at pathogenic autoantibodies and alloantibodies. We also explore the novel modifications of therapeutic monoclonals that exploit FcRn functions to enhance therapeutic efficacy.
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Sasson SC, Corbett A, McLachlan AJ, Chen R, Adelstein SA, Riminton S, Limaye S. Enhanced serum immunoglobulin G clearance in myotonic dystrophy-associated hypogammaglobulinemia: a case series and review of the literature. J Med Case Rep 2019; 13:338. [PMID: 31744540 PMCID: PMC6864924 DOI: 10.1186/s13256-019-2285-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 10/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myotonic dystrophy type 1 is an autosomal dominant disorder characterized by muscle weakness, myotonia, cataracts, and cardiac conduction defects; it is associated with expansions of cytosine-thymine-guanine repeats in the myotonic dystrophy protein kinase. Hypogammaglobulinemia is a lesser known association of myotonic dystrophy type 1 and the underlying pathogenesis of immunoglobulin G depletion remains unclear. CASE PRESENTATION Here we report a kindred of two members (a 62-year-old white woman and a 30-year-old white man; mother and son) with myotonic dystrophy type 1-associated hypogammaglobulinemia associated with altered intravenous immunoglobulin elimination kinetics and reduced half-life. There was no history of systemic immunosuppression or renal or gastrointestinal protein loss in either patient, and no underlying case for a secondary immunodeficiency could be found. One patient required fortnightly intravenous immunoglobulin to maintain adequate trough immunoglobulin G levels. CONCLUSIONS Ongoing study of myotonic dystrophy type 1-associated hypogammaglobulinemia using contemporary tools of genomic medicine may help to further delineate the pathogenesis of this entity.
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Affiliation(s)
- Sarah C Sasson
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Level 5, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | | | | | - R Chen
- Immunopathology Laboratory, Department of Clinical Immunology, Royal Prince Alfred Hospital, Sydney, Australia
| | - S A Adelstein
- Immunopathology Laboratory, Department of Clinical Immunology, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Sean Riminton
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Clinical Immunology, Concord Hospital, Sydney, Australia
| | - Sandhya Limaye
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Clinical Immunology, Concord Hospital, Sydney, Australia
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Patel SY, Carbone J, Jolles S. The Expanding Field of Secondary Antibody Deficiency: Causes, Diagnosis, and Management. Front Immunol 2019; 10:33. [PMID: 30800120 PMCID: PMC6376447 DOI: 10.3389/fimmu.2019.00033] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022] Open
Abstract
Antibody deficiency or hypogammaglobulinemia can have primary or secondary etiologies. Primary antibody deficiency (PAD) is the result of intrinsic genetic defects, whereas secondary antibody deficiency may arise as a consequence of underlying conditions or medication use. On a global level, malnutrition, HIV, and malaria are major causes of secondary immunodeficiency. In this review we consider secondary antibody deficiency, for which common causes include hematological malignancies, such as chronic lymphocytic leukemia or multiple myeloma, and their treatment, protein-losing states, and side effects of a number of immunosuppressive agents and procedures involved in solid organ transplantation. Secondary antibody deficiency is not only much more common than PAD, but is also being increasingly recognized with the wider and more prolonged use of a growing list of agents targeting B cells. SAD may thus present to a broad range of specialties and is associated with an increased risk of infection. Early diagnosis and intervention is key to avoiding morbidity and mortality. Optimizing treatment requires careful clinical and laboratory assessment and may involve close monitoring of risk parameters, vaccination, antibiotic strategies, and in some patients, immunoglobulin replacement therapy (IgRT). This review discusses the rapidly evolving list of underlying causes of secondary antibody deficiency, specifically focusing on therapies targeting B cells, alongside recent advances in screening, biomarkers of risk for the development of secondary antibody deficiency, diagnosis, monitoring, and management.
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Affiliation(s)
- Smita Y. Patel
- Clinical Immunology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Javier Carbone
- Clinical Immunology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
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Abstract
Myotonic dystrophy is an autosomal dominant muscular dystrophy not only associated with muscle weakness, atrophy, and myotonia but also prominent multisystem involvement. There are 2 similar, but distinct, forms of myotonic dystrophy; type 1 is caused by a CTG repeat expansion in the DMPK gene, and type 2 is caused by a CCTG repeat expansion in the CNBP gene. Type 1 is associated with distal limb, neck flexor, and bulbar weakness and results in different phenotypic subtypes with variable onset from congenital to very late-onset as well as variable signs and symptoms. The classically described adult-onset form is the most common. In contrast, myotonic dystrophy type 2 is adult-onset or late-onset, has proximal predominant muscle weakness, and generally has less severe multisystem involvement. In both forms of myotonic dystrophy, the best characterized disease mechanism is a RNA toxic gain-of-function during which RNA repeats form nuclear foci resulting in sequestration of RNA-binding proteins and, therefore, dysregulated splicing of premessenger RNA. There are currently no disease-modifying therapies, but clinical surveillance, preventative measures, and supportive treatments are used to reduce the impact of muscular impairment and other systemic involvement including cataracts, cardiac conduction abnormalities, fatigue, central nervous system dysfunction, respiratory weakness, dysphagia, and endocrine dysfunction. Exciting preclinical progress has been made in identifying a number of potential strategies including genome editing, small molecule therapeutics, and antisense oligonucleotide-based therapies to target the pathogenesis of type 1 and type 2 myotonic dystrophies at the DNA, RNA, or downstream target level.
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Affiliation(s)
- Samantha LoRusso
- Department of Neurology, The Ohio State University, 395 West 12th Avenue, Columbus, OH, 43210, USA
| | - Benjamin Weiner
- The Ohio State University College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, OH, 43210, USA
| | - W David Arnold
- Department of Neurology, The Ohio State University, 395 West 12th Avenue, Columbus, OH, 43210, USA.
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9
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Jolles S, Chapel H, Litzman J. When to initiate immunoglobulin replacement therapy (IGRT) in antibody deficiency: a practical approach. Clin Exp Immunol 2017; 188:333-341. [PMID: 28000208 DOI: 10.1111/cei.12915] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2016] [Indexed: 12/13/2022] Open
Abstract
Primary antibody deficiencies (PAD) constitute the majority of all primary immunodeficiency diseases (PID) and immunoglobulin replacement forms the mainstay of therapy for many patients in this category. Secondary antibody deficiencies (SAD) represent a larger and expanding number of patients resulting from the use of a wide range of immunosuppressive therapies, in particular those targeting B cells, and may also result from renal or gastrointestinal immunoglobulin losses. While there are clear similarities between primary and secondary antibody deficiencies, there are also significant differences. This review describes a practical approach to the clinical, laboratory and radiological assessment of patients with antibody deficiency, focusing on the factors that determine whether or not immunoglobulin replacement should be used. The decision to treat is more straightforward when defined diagnostic criteria for some of the major PADs, such as common variable immunodeficiency disorders (CVID) or X-linked agammaglobulinaemia (XLA), are fulfilled or, indeed, when there is a very low level of immunoglobulin production in association with an increased frequency of severe or recurrent infections in SAD. However, the presentation of many patients is less clear-cut and represents a considerable challenge in terms of the decision whether or not to treat and the best way in which to assess the outcome of therapy. This decision is important, not least to improve individual quality of life and reduce the morbidity and mortality associated with recurrent infections but also to avoid inappropriate exposure to blood products and to ensure that immunoglobulin, a costly and limited resource, is used to maximal benefit.
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Affiliation(s)
- S Jolles
- Immunodeficiency Centre for Wales, Department of Immunology, University Hospital of Wales, Cardiff, UK
| | - H Chapel
- Department of Clinical Immunology, University of Oxford, UK
| | - J Litzman
- Department of Clinical Immunology and Allergology, St Annes's University Hospital, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Fox R, Ealing J, Murphy H, Gow DP, Gosal D. A novel DNMT1
mutation associated with early onset hereditary sensory and autonomic neuropathy, cataplexy, cerebellar atrophy, scleroderma, endocrinopathy, and common variable immune deficiency. J Peripher Nerv Syst 2016; 21:150-3. [DOI: 10.1111/jns.12178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 05/30/2016] [Accepted: 06/06/2016] [Indexed: 01/11/2023]
Affiliation(s)
- Robin Fox
- Department of Neurology; Salford Royal NHS Foundation Trust; Manchester UK
| | - John Ealing
- Department of Neurology; Salford Royal NHS Foundation Trust; Manchester UK
| | - Helen Murphy
- Manchester Centre for Genomic Medicine; St Mary's Hospital; Manchester UK
| | - David P. Gow
- Department of Neurology; Dunedin Public Hospital; Dunedin New Zealand
| | - David Gosal
- Department of Neurology; Salford Royal NHS Foundation Trust; Manchester UK
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11
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Peña-Irún A, González-Santamaría A, Munguía-Rozadilla F, Helguera-Rebolledo F. Infección respiratoria por Pseudomona aeruginosa adquirida en la comunidad en un paciente con enfermedad de Steinert e hipogammaglobulinemia. Semergen 2016; 42:340-1. [DOI: 10.1016/j.semerg.2015.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 05/08/2015] [Accepted: 05/12/2015] [Indexed: 11/16/2022]
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Finsterer J, Stöllberger C, Demirtas D, Gencik M, Ohnutek I, Hornykewycz A. Recurrent takotsubo syndrome in a patient with myotonic dystrophy 1. ACTA ACUST UNITED AC 2014; 16:115-7. [DOI: 10.3109/17482941.2014.944538] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kaminsky P, Pruna L. [A genetic systemic disease: clinical description of type 1 myotonic dystrophy in adults]. Rev Med Interne 2012; 33:514-8. [PMID: 22572587 DOI: 10.1016/j.revmed.2012.03.355] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 03/31/2012] [Indexed: 01/06/2023]
Abstract
Type 1 myotonic dystrophy is an autosomal dominant inherited disorder related to the expansion of a trinucleotide (CTG) repeat in the exon 15 in the 3'-untranslated region of the myotonic dystrophy protein kinase (DMPK) gene. Mutant transcripts containing an expanded CUG repeat are retained in nuclear foci and cause numerous dysfunctions by interfering with biogenesis of other mRNAs. Prominent clinical features are progressive muscular weakness and myotonia, which affect skeletal muscles but also white muscles leading to digestive, urinary and obstetrical disorders. Functional prognosis correlates with motor handicap and vital prognosis is linked to cardiac rhythm disturbances and conduction defects due to progressive subendocardial fibrosis, and to complex respiratory dysfunctions, which associate restrictive lung disease, involvement of the central inspiratory pathway, and sleep apnea. Other clinical features are lens opacity, glucose intolerance, metabolic syndrome, several endocrine disorders (gonadal deficiency, hyperparathydoidism), or immunoglobulin deficiency due to immunoglobulin G hypercatabolism. Life expectancy is reduced in myotonic dystrophy, and death is mainly caused by respiratory complications, but also by cardiac arrhythmias. Moreover, an abnormal incidence of tumors has been reported. Therefore, myotonic dystrophy does not only concern neurologists but a multidisciplinary approach is necessary, including at least pneumologist, cardiologist, and physiotherapist. General internists should also be implicated, not only in the initial diagnosis step, but also in the diagnosis of complications and their treatments.
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Affiliation(s)
- P Kaminsky
- Service de médecine interne orientée vers les maladies orphelines et systémiques, pôle des spécialités médicales, centre de référence des maladies neuromusculaires de Nancy, centre hospitalier universitaire de Nancy, hôpitaux de Brabois, rue du Morvan, 54511 Vandœuvre cedex, France
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