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Finsterer J, Strobl W. Gastrointestinal involvement in neuromuscular disorders. J Gastroenterol Hepatol 2024. [PMID: 38859699 DOI: 10.1111/jgh.16650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/30/2024] [Accepted: 05/25/2024] [Indexed: 06/12/2024]
Abstract
Although not often discussed, many of the neuromuscular disorders (NMDs) affect the gastrointestinal tract (GIT). Depending on the type of NMD, the prevalence of GIT involvement ranges from <5% (e.g. hereditary neuropathies, myofibrillar myopathies) to 100% (e.g. MNGIE, OPMD). Particularly in NMDs with multisystem affection, involvement of the GIT can dominate the clinical presentation or at least make up a significant part of the clinical picture. The most prominent representatives of NMDs with multisystem involvement are the mitochondrial disorders (MIDs) and the myotonic dystrophies. The best known syndromic MIDs with GIT involvement are MNGIE, MELAS, Leigh, and Pearson syndromes. Among neuropathies, GIT involvement is most commonly found in ALS and GBS. GIT involvement may also be a feature of myasthenia. The clinical manifestations of GIT involvement are diverse and can affect the entire GIT, from the teeth to the rectum, including the liver and pancreas. The most well-known clinical manifestations of GIT involvement are dysphagia, nausea, vomiting, reflux, hollow organ dysmotility, hepatopathy, diabetes, diarrhea, constipation, and fecal incontinence. Even if treatment can usually only be symptomatic, the therapeutic options are diverse, are often effective, and can significantly and beneficially influence the course of the underlying NMD.
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Affiliation(s)
| | - Walter Strobl
- Department of Health Sciences, Medicine and Research, Danube University for Continuing Education Krems and MOTIO, Vienna, Austria
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2
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Alcalá-González LG, Accarino A, Martí R, Sánchez-Tejerina D, Llauradó A, Azpiroz F, Malagelada C. Distinctive gastrointestinal motor dysfunction in patients with MNGIE. Neurogastroenterol Motil 2023; 35:e14643. [PMID: 37448106 DOI: 10.1111/nmo.14643] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/25/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare mitochondrial disease caused by mutations in TYMP, encoding thymidine phosphorylase. Clinically it is characterized by severe gastrointestinal dysmotility associated with cachexia and a demyelinating sensorimotor polyneuropathy. Even though digestive manifestations are progressive and invariably lead to death, the features of gastrointestinal motor dysfunction have not been systematically evaluated. The objective of this study was to describe gastrointestinal motor dysfunction in MNGIE using state-of-the art techniques and to evaluate the relationship between motor abnormalities and symptoms. METHODS Prospective study evaluating gastrointestinal motor function and digestive symptoms in all patients with MNGIE attended at a national referral center in Spain between January 2018 and July 2022. KEY RESULTS In this period, five patients diagnosed of MNGIE (age range 16-46 years, four men) were evaluated. Esophageal motility by high-resolution manometry was abnormal in four patients (two hypoperistalsis, two aperistalsis). Gastric emptying by scintigraphy was mildly delayed in four and indicative of gastroparesis in one. In all patients, small bowel high-resolution manometry exhibited a common, distinctive dysmotility pattern, characterized by repetitive bursts of spasmodic contractions, without traces of normal fasting and postprandial motility patterns. Interestingly, objective motor dysfunctions were detected in the absence of severe digestive symptoms. CONCLUSIONS AND INFERENCES MNGIE patients exhibit a characteristic motor dysfunction, particularly of the small bowel, even in patients with mild digestive symptoms and in the absence of morphological signs of intestinal failure. Since symptoms are not predictive of objective findings, early investigation is indicated.
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Affiliation(s)
- Luis G Alcalá-González
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Anna Accarino
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Ramon Martí
- Research Group on Neuromuscular and Mitochondrial Disorders, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain
- Biomedical Network Research Centre on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Daniel Sánchez-Tejerina
- Clinic of Neuromuscular Disorders and Rare Diseases, Neurology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Barcelona, Spain
- European Reference Network for Neuromuscular and Rare Diseases EURO-NMD, Barcelona, Spain
| | - Arnau Llauradó
- Clinic of Neuromuscular Disorders and Rare Diseases, Neurology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Barcelona, Spain
- European Reference Network for Neuromuscular and Rare Diseases EURO-NMD, Barcelona, Spain
| | - Fernando Azpiroz
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
| | - Carolina Malagelada
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Barcelona, Spain
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3
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Salazar D, Kloke KM, Guerrero RB, Ferreira CR, Blau N. Clinical and biochemical footprints of inherited metabolic disorders. XI. Gastrointestinal symptoms. Mol Genet Metab 2023; 138:107528. [PMID: 36774919 PMCID: PMC10509718 DOI: 10.1016/j.ymgme.2023.107528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/28/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
Inherited metabolic disorders presenting with gastrointestinal (GI) symptoms are characterized by the dysfunction of the esophagus, stomach, small and large intestines, and pancreas. We have summarized associations of signs and symptoms in 339 inherited metabolic diseases presenting with GI symptoms. Feeding difficulties represent the most common abnormality reported for IMDs with GI involvement (37%) followed by intestinal problems (30%), vomiting (22%), stomach and pancreas involvement (8% each), and esophagus involvement (4%). This represents the eleventh of a series of articles attempting to create and maintain a comprehensive list of clinical and metabolic differential diagnoses according to system involvement.
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Affiliation(s)
- Denise Salazar
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, United States of America.
| | - Karen M Kloke
- Mayo Clinic Laboratories, Rochester, MN, United States of America.
| | | | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States of America.
| | - Nenad Blau
- Division of Metabolism, University Children's Hospital, Zürich, Switzerland.
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Bianco F, Lattanzio G, Lorenzini L, Mazzoni M, Clavenzani P, Calzà L, Giardino L, Sternini C, Costanzini A, Bonora E, De Giorgio R. Enteric Neuromyopathies: Highlights on Genetic Mechanisms Underlying Chronic Intestinal Pseudo-Obstruction. Biomolecules 2022; 12:biom12121849. [PMID: 36551277 PMCID: PMC9776039 DOI: 10.3390/biom12121849] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/04/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Severe gut motility disorders are characterized by the ineffective propulsion of intestinal contents. As a result, the patients develop disabling/distressful symptoms, such as nausea and vomiting along with altered bowel habits up to radiologically demonstrable intestinal sub-obstructive episodes. Chronic intestinal pseudo-obstruction (CIPO) is a typical clinical phenotype of severe gut dysmotility. This syndrome occurs due to changes altering the morpho-functional integrity of the intrinsic (enteric) innervation and extrinsic nerve supply (hence neuropathy), the interstitial cells of Cajal (ICC) (mesenchymopathy), and smooth muscle cells (myopathy). In the last years, several genes have been identified in different subsets of CIPO patients. The focus of this review is to cover the most recent update on enteric dysmotility related to CIPO, highlighting (a) forms with predominant underlying neuropathy, (b) forms with predominant myopathy, and (c) mitochondrial disorders with a clear gut dysfunction as part of their clinical phenotype. We will provide a thorough description of the genes that have been proven through recent evidence to cause neuro-(ICC)-myopathies leading to abnormal gut contractility patterns in CIPO. The discovery of susceptibility genes for this severe condition may pave the way for developing target therapies for enteric neuro-(ICC)-myopathies underlying CIPO and other forms of gut dysmotility.
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Affiliation(s)
- Francesca Bianco
- Department of Veterinary Sciences, University of Bologna, 40064 Ozzano Emilia, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
| | - Giulia Lattanzio
- Department of Veterinary Sciences, University of Bologna, 40064 Ozzano Emilia, Italy
| | - Luca Lorenzini
- Department of Veterinary Sciences, University of Bologna, 40064 Ozzano Emilia, Italy
| | - Maurizio Mazzoni
- Department of Veterinary Sciences, University of Bologna, 40064 Ozzano Emilia, Italy
| | - Paolo Clavenzani
- Department of Veterinary Sciences, University of Bologna, 40064 Ozzano Emilia, Italy
| | - Laura Calzà
- IRET Foundation, 40064 Ozzano Emilia, Italy
- Department of Pharmacy and Biotechnology, University of Bologna, 40126 Bologna, Italy
| | - Luciana Giardino
- Department of Veterinary Sciences, University of Bologna, 40064 Ozzano Emilia, Italy
- IRET Foundation, 40064 Ozzano Emilia, Italy
| | - Catia Sternini
- UCLA/DDRC, Division of Digestive Diseases, Departments Medicine and Neurobiology, David Geffen School of Medicine, UCLA, Los Angeles, CA 90001, USA
| | - Anna Costanzini
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
| | - Elena Bonora
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
- Correspondence: (E.B.); (R.D.G.); Tel.: +39-051-2094761 (E.B.); +39-0532-236631 (R.D.G.)
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Correspondence: (E.B.); (R.D.G.); Tel.: +39-051-2094761 (E.B.); +39-0532-236631 (R.D.G.)
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Boschetti E, Caporali L, D’Angelo R, Malagelada C, Accarino A, Dotti MT, Costa R, Cenacchi G, Pironi L, Rinaldi R, Stanghellini V, Ratti S, Manzoli L, Carelli V, De Giorgio R. Anatomical Laser Microdissection of the Ileum Reveals mtDNA Depletion Recovery in A Mitochondrial Neuro-Gastrointestinal Encephalomyopathy (MNGIE) Patient Receiving Liver Transplant. Int J Mol Sci 2022; 23:ijms23158792. [PMID: 35955927 PMCID: PMC9369323 DOI: 10.3390/ijms23158792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/22/2022] Open
Abstract
mitochondrial neuro-gastrointestinal encephalomyopathy (MNGIE) is a rare genetic disorder characterized by thymidine phosphorylase (TP) enzyme defect. The absence of TP activity induces the imbalance of mitochondrial nucleotide pool, leading to impaired mitochondrial DNA (mtDNA) replication and depletion. Since mtDNA is required to ensure oxidative phosphorylation, metabolically active tissues may not achieve sufficient energy production. The only effective life-saving approach in MNGIE has been the permanent replacement of TP via allogeneic hematopoietic stem cell or liver transplantation. However, the follow-up of transplanted patients showed that gut tissue changes do not revert and fatal complications, such as massive gastrointestinal bleeding, can occur. The purpose of this study was to clarify whether the reintroduction of TP after transplant can recover mtDNA copy number in a normal range. Using laser capture microdissection and droplet-digital-PCR, we assessed the mtDNA copy number in each layer of full-thickness ileal samples of a naive MNGIE cohort vs. controls and in a patient pre- and post-TP replacement. The treatment led to a significant recovery of gut tissue mtDNA amount, thus showing its efficacy. Our results indicate that a timely TP replacement is needed to maximize therapeutic success before irreversible degenerative tissue changes occur in MNGIE.
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Affiliation(s)
- Elisa Boschetti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy
- Correspondence: (E.B.); (V.C.)
| | - Leonardo Caporali
- IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Roberto D’Angelo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy
| | - Carolina Malagelada
- Centro de Investigacion Biomedica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University Hospital Vall d’Hebron, 08035 Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, 08035 Barcelona, Spain
| | - Anna Accarino
- Centro de Investigacion Biomedica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University Hospital Vall d’Hebron, 08035 Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, 08035 Barcelona, Spain
| | - Maria Teresa Dotti
- Department of Medical, Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy
| | - Roberta Costa
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy
| | - Giovanna Cenacchi
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy
| | - Loris Pironi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Rita Rinaldi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy
| | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Stefano Ratti
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy
| | - Lucia Manzoli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy
| | - Valerio Carelli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
- Correspondence: (E.B.); (V.C.)
| | - Roberto De Giorgio
- Department of Translational Medicine, University of Ferrara, 44124 Ferrara, Italy
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6
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Houghton D, Ng YS, Jackson MA, Stefanetti R, Hynd P, Mac Aogáin M, Stewart CJ, Lamb CA, Bright A, Feeney C, Newman J, Turnbull DM, McFarland R, Blain AP, Gorman GS. Phase II Feasibility Study of the Efficacy, Tolerability, and Impact on the Gut Microbiome of a Low-Residue (Fiber) Diet in Adult Patients With Mitochondrial Disease. GASTRO HEP ADVANCES 2022; 1:666-677. [PMID: 39132075 PMCID: PMC11307892 DOI: 10.1016/j.gastha.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/16/2022] [Indexed: 08/13/2024]
Abstract
Background and Aims Gastrointestinal (GI) dysmotility is a common and debilitating clinical manifestation in patients with mitochondrial DNA (mtDNA)-related disease with no curative and few effective symptomatic therapies. A low-residue diet (LRD) has been shown to be effective at reducing bowel urgency, pain, and distension in functional GI-related conditions. We assessed tolerability and effects of an LRD on bowel habits in patients with mtDNA-related disease. Methods This was a 12-week single-arm pilot study in patients with genetically determined primary mtDNA-related disease, meeting the ROME III constipation criteria. The co-primary outcomes were tolerability of an LRD (<10 g fiber per day) assessed by food diaries and changes in stool frequency and consistency. The secondary outcomes included GI symptoms, disease burden, laxatives, physical activity levels, colonic transit time using radiopaque markers, gut microbiome (patients and controls), and metabolomics. The gut microbiome of the mtDNA-related disease patients was compared against controls for observational purpose only. Results Twenty-eight patients were enrolled, and 24 completed the LRD intervention. The LRD was well tolerated with a mean fold change of -34% in dietary fiber (5.3 ± 10.4 grams) per day (P = .03, confidence interval = 0.7-9.9) with no adverse events. The proportion of stool samples with normal stool consistency increased from 36% to 49% (P = .01); GI symptoms and laxative use were reduced. However, the LRD did not change stool frequency, stool output, and colonic transit time. The gut microbiome was significantly different between patients and controls but was not modulated by the dietary intervention. Conclusion The LRD in patients with mtDNA-related mitochondrial disease and significant constipation is well tolerated and a promising treatment for alleviating GI symptoms. These positive findings should be confirmed in a randomized controlled trial.ClinicalTrials.gov Identifier: NCT03388528.
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Affiliation(s)
- David Houghton
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | - Yi Shiau Ng
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | | | - Renae Stefanetti
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | - Paula Hynd
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | - Micheál Mac Aogáin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Novena, Singapore
- Biochemical Genetics Laboratory, Department of Biochemistry, St. James Hospital, Dublin, Ireland
| | - Christopher J. Stewart
- Faculty of Medical Science, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher A. Lamb
- Faculty of Medical Science, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alexandra Bright
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | - Catherine Feeney
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | - Jane Newman
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | - Doug M. Turnbull
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | - Robert McFarland
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | - Alasdair P. Blain
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
| | - Gráinne S. Gorman
- Faculty of Medical Science, Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle on Tyne, UK
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Kamperidis N, Nightingale J. Neurological disorders and small bowel dysmotility. Curr Opin Gastroenterol 2022; 38:299-306. [PMID: 35645022 DOI: 10.1097/mog.0000000000000836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Small bowel dysmotility is common in the context of neurological disorders. Overlooking it can have an adverse impact on patient's quality of life and neurological outcomes. This review focuses on describing the mechanisms and effects of enteric dysmotility in neurological patients and providing treatment options. RECENT FINDINGS Small bowel dysmotility is prevalent among neurological patients. The definition and diagnosis of small bowel dysmotility is a challenge; however, up to two-thirds of neurological patients may experience associated symptoms. Small bowel dysmotility can affect the absorption of nutrients and medication, impacts on social and professional function and can result in malnutrition and its associated morbidity and mortality. SUMMARY Small bowel dysmotility due to a neuropathy can result from acute or chronic disorders in the central and peripheral nervous system and includes the cerebral cortex, brain stem, spinal cord, parasympathetic (vagus) and sympathetic nerves and the myenteric and submucosal plexuses of the intestine. Generalized muscle disorders can also cause an enteral myopathy. Generally, the disorders may be degenerative or inflammatory. Both enteric neuropathy and myopathy may cause symptoms of abdominal pain, nausea/vomiting, bloating, constipation or diarrhoea and can cause malnutrition. The symptoms need to be addressed in order of importance to the patient and malnutrition prevented or treated.
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Paisiou A, Rogalidou M, Pons R, Ioannidou E, Dimakou K, Papadopoulou A, Vaz FM, Vessalas G, Goorden SMI, Roelofsen J, Zoetekouw A, Nieman MM, Dimitriou E, Moraitou M, Peristeri I, Michelakakis H, van Kuilenburg ABP. Mitochondrial neurogastrointestinal encephalomyopathy: Clinical and biochemical impact of allogeneic stem cell transplantation in a Greek patient with one novel TYMP mutation. Mol Genet Metab Rep 2021; 30:100829. [PMID: 34926160 PMCID: PMC8649387 DOI: 10.1016/j.ymgmr.2021.100829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/01/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
We describe the case of a Greek female patient with the Classic form of the ultra- rare and fatal autosomal recessive disorder Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) and the impact of allogeneic hematopoietic stem cell transplantation on the biochemical and clinical aspects of the disease. The patient presented at the age of 15 years with severe gastrointestinal symptoms, cachexia, peripheral neuropathy and diffuse leukoencephalopathy. The diagnosis of MNGIE disease was established by the increased levels of thymidine and deoxyuridine in plasma and the complete deficiency of thymidine phosphorylase activity. The novel c.[978dup] (p.Ala327Argfs*?) variant and the previously described variant c.[417 + 1G > A] were identified in TYMP. The donor for the allogeneic hematopoietic stem cell transplantation was her fully compatible sister, a carrier of the disease. The patient had a completely uneventful post- transplant period and satisfactory PB chimerism levels. A marked and rapid decrease in thymidine and deoxyuridine plasma levels and an increase of the thymidine phosphorylase activity to the levels measured in her donor sister was observed and is still present sixteen months post-transplant. Disease symptoms stabilized and some improvement was also observed both in her neurological and gastrointestinal symptoms. Follow up studies will be essential for determining the long term impact of allogeneic hematopoietic stem cell transplantation in our patient.
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Key Words
- AHSCT, allogeneic hematopoietic stem cell transplantation;
- Allogeneic hematopoietic stem cell transplantation, AHSCT
- CSF, cerebrospinal fluid;
- GVHD, Graft Versus Host Disease;
- HSCT, hematopoietic stem cell transplantation;
- MNGIE
- MNGIE, mitochondrial neurogastrointestinal encephalomyopathy;
- Mitochondrial neurogastrointestinal encephalomyopathy
- Mutation analysis
- OLT, orthotopic liver transplantation;
- PB, peripheral blood;
- PLT, platelet;
- TP, thymidine phosphorylase;
- TPN, total parenteral nutrition;
- TYMP, thymidine phosphorylase gene;
- VLCFA, very long chain fatty acids
- dThd, thymidine;
- dUrd, 2′-deoxyuridine;
- mtDNA, mitochondrial DNA;
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Affiliation(s)
- A Paisiou
- Stem Cell Transplant Unit, Agia Sofia Children's Hospital, Athens, Greece
| | - M Rogalidou
- Division of Paediatric Gastroenterology & Hepatology, 1st Department of Paediatrics, National and Kapodistrian University of Athens, Agia Sofia Children's Hospital, Athens, Greece
| | - R Pons
- Pediatric Neurology Unit, 1st Department of Pediatrics, , Agia Sofia Children's Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - E Ioannidou
- Stem Cell Transplant Unit, Agia Sofia Children's Hospital, Athens, Greece
| | - K Dimakou
- Division of Paediatric Gastroenterology & Hepatology, 1st Department of Paediatrics, National and Kapodistrian University of Athens, Agia Sofia Children's Hospital, Athens, Greece
| | - A Papadopoulou
- Division of Paediatric Gastroenterology & Hepatology, 1st Department of Paediatrics, National and Kapodistrian University of Athens, Agia Sofia Children's Hospital, Athens, Greece
| | - F M Vaz
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Core Facility Metabolomics, Amsterdam UMC, the Netherlands
| | - G Vessalas
- Stem Cell Transplant Unit, Agia Sofia Children's Hospital, Athens, Greece
| | - S M I Goorden
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - J Roelofsen
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - A Zoetekouw
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - M M Nieman
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - E Dimitriou
- Department of Enzymology and Cellular Function, Institute of Child Health, Athens, Greece
| | - M Moraitou
- Department of Enzymology and Cellular Function, Institute of Child Health, Athens, Greece
| | - I Peristeri
- Stem Cell Transplant Unit, Agia Sofia Children's Hospital, Athens, Greece
| | - H Michelakakis
- Department of Enzymology and Cellular Function, Institute of Child Health, Athens, Greece
| | - A B P van Kuilenburg
- Laboratory Genetic Metabolic Diseases, Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
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9
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Bianco F, Lattanzio G, Lorenzini L, Diquigiovanni C, Mazzoni M, Clavenzani P, Calzà L, Giardino L, Sternini C, Bonora E, De Giorgio R. Novel understanding on genetic mechanisms of enteric neuropathies leading to severe gut dysmotility. Eur J Histochem 2021; 65. [PMID: 34818877 PMCID: PMC8636838 DOI: 10.4081/ejh.2021.3289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/03/2021] [Indexed: 11/24/2022] Open
Abstract
The enteric nervous system (ENS) is the third division of the autonomic nervous system and the largest collection of neurons outside the central nervous system (CNS). The ENS has been referred to as “the brain-in-thegut” or “the second brain of the human body” because of its highly integrated neural circuits controlling a vast repertoire of gut functions, including absorption/secretion, splanchnic blood vessels, some immunological aspects, intestinal epithelial barrier, and gastrointestinal (GI) motility. The latter function is the result of the ENS fine-tuning over smooth musculature, along with the contribution of other key cells, such as enteric glia (astrocyte-like cells supporting and contributing to neuronal activity), interstitial cells of Cajal (the pacemaker cells of the GI tract involved in neuromuscular transmission), and enteroendocrine cells (releasing bioactive substances, which affect gut physiology). Any noxa insult perturbing the ENS complexity may determine a neuropathy with variable degree of neuro-muscular dysfunction. In this review we aim to cover the most recent update on genetic mechanisms leading to enteric neuropathies ranging from Hirschsprung’s disease (characterized by lack of any enteric neurons in the gut wall) up to more generalized form of dysmotility such as chronic intestinal pseudo-obstruction (CIPO) with a significant reduction of enteric neurons. In this line, we will discuss the role of the RAD21 mutation, which we have demonstrated in a family whose affected members exhibited severe GI dysmotility. Other genes contributing to gut motility abnormalities will also be presented. In conclusion, the knowledge on the molecular mechanisms involved in enteric neuropathy may unveil strategies to better manage patients with neurogenic gut dysmotility and pave the way to targeted therapies.
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Affiliation(s)
- Francesca Bianco
- Department of Veterinary Sciences; Department of Medical and Surgical Sciences, University of Bologna.
| | | | | | | | | | | | | | | | - Catia Sternini
- UCLA/DDRC, Division of Digestive Diseases, Departments Medicine and Neurobiology, David Geffen School of Medicine, UCLA, Los Angeles CA.
| | - Elena Bonora
- Department of Medical and Surgical Sciences, University of Bologna.
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10
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Boschetti E, D’Angelo R, Tardio ML, Costa R, Giordano C, Accarino A, Malagelada C, Clavenzani P, Tugnoli V, Caio G, Righi V, Garone C, D'Errico A, Cenacchi G, Dotti MT, Stanghellini V, Sternini C, Pironi L, Rinaldi R, Carelli V, De Giorgio R. Evidence of enteric angiopathy and neuromuscular hypoxia in patients with mitochondrial neurogastrointestinal encephalomyopathy. Am J Physiol Gastrointest Liver Physiol 2021; 320:G768-G779. [PMID: 33655764 PMCID: PMC8202202 DOI: 10.1152/ajpgi.00047.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare autosomal recessive disease caused by thymidine phosphorylase (TP) enzyme defect. As gastrointestinal changes do not revert in patients undergone TP replacement therapy, one can postulate that other unexplored mechanisms contribute to MNGIE pathophysiology. Hence, we focused on the local TP angiogenic potential that has never been considered in MNGIE. In this study, we investigated the enteric submucosal microvasculature and the effect of hypoxia on fibrosis and enteric neurons density in jejunal full-thickness biopsies collected from patients with MNGIE. Orcein staining was used to count blood vessels based on their size. Fibrosis was assessed using the Sirius Red and Fast Green method. Hypoxia and neoangiogenesis were determined via hypoxia-inducible-factor-1α (HIF-1α) and vascular endothelial cell growth factor (VEGF) protein expression, respectively. Neuron-specific enolase was used to label enteric neurons. Compared with controls, patients with MNGIE showed a decreased area of vascular tissue, but a twofold increase of submucosal vessels/mm2 with increased small size and decreased medium and large size vessels. VEGF positive vessels, fibrosis index, and HIF-1α protein expression were increased, whereas there was a diminished thickness of the longitudinal muscle layer with an increased interganglionic distance and reduced number of myenteric neurons. We demonstrated the occurrence of an angiopathy in the GI tract of patients with MNGIE. Neoangiogenetic changes, as detected by the abundance of small size vessels in the jejunal submucosa, along with hypoxia provide a morphological basis to explain neuromuscular alterations, vasculature breakdown, and ischemic abnormalities in MNGIE.NEW & NOTEWORTHY Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is characterized by a genetically driven defect of thymidine phosphorylase, a multitask enzyme playing a role also in angiogenesis. Indeed, major gastrointestinal bleedings are life-threatening complications of MNGIE. Thus, we focused on jejunal submucosal vasculature and showed intestinal microangiopathy as a novel feature occurring in this disease. Notably, vascular changes were associated with neuromuscular abnormalities, which may explain gut dysfunction and help to develop future therapeutic approaches in MNGIE.
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Affiliation(s)
- Elisa Boschetti
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy,2Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto D’Angelo
- 3IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC interaziendale Clinica Neurologica Metropolitana (NeuroMet), Neurologia AOU S. Orsola-Malpighi, Bologna, Italy
| | | | - Roberta Costa
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Carla Giordano
- 5Department of Medico-Surgical Sciences and Biotechnologies, University “La Sapienza”, Roma, Italy
| | - Anna Accarino
- 6Digestive System Research Unit, University Hospital Vall d'Hebron;
Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD); Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carolina Malagelada
- 6Digestive System Research Unit, University Hospital Vall d'Hebron;
Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD); Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Paolo Clavenzani
- 7Department of Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Vitaliano Tugnoli
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giacomo Caio
- 8Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Valeria Righi
- 9Department of Life Quality Studies, University of Bologna, Bologna, Italy
| | - Caterina Garone
- 2Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Giovanna Cenacchi
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Maria Teresa Dotti
- 10Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | | | - Catia Sternini
- 11Digestive-Disease-Division, Departments of Medicine and Neurobiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Loris Pironi
- 2Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Rita Rinaldi
- 3IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC interaziendale Clinica Neurologica Metropolitana (NeuroMet), Neurologia AOU S. Orsola-Malpighi, Bologna, Italy
| | - Valerio Carelli
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy,12IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Roberto De Giorgio
- 8Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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11
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Filograna R, Mennuni M, Alsina D, Larsson NG. Mitochondrial DNA copy number in human disease: the more the better? FEBS Lett 2020; 595:976-1002. [PMID: 33314045 PMCID: PMC8247411 DOI: 10.1002/1873-3468.14021] [Citation(s) in RCA: 217] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/02/2020] [Accepted: 11/26/2020] [Indexed: 12/19/2022]
Abstract
Most of the genetic information has been lost or transferred to the nucleus during the evolution of mitochondria. Nevertheless, mitochondria have retained their own genome that is essential for oxidative phosphorylation (OXPHOS). In mammals, a gene‐dense circular mitochondrial DNA (mtDNA) of about 16.5 kb encodes 13 proteins, which constitute only 1% of the mitochondrial proteome. Mammalian mtDNA is present in thousands of copies per cell and mutations often affect only a fraction of them. Most pathogenic human mtDNA mutations are recessive and only cause OXPHOS defects if present above a certain critical threshold. However, emerging evidence strongly suggests that the proportion of mutated mtDNA copies is not the only determinant of disease but that also the absolute copy number matters. In this review, we critically discuss current knowledge of the role of mtDNA copy number regulation in various types of human diseases, including mitochondrial disorders, neurodegenerative disorders and cancer, and during ageing. We also provide an overview of new exciting therapeutic strategies to directly manipulate mtDNA to restore OXPHOS in mitochondrial diseases.
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Affiliation(s)
- Roberta Filograna
- Division of Molecular Metabolism, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden.,Max Planck Institute for Biology of Ageing - Karolinska Institutet Laboratory, Karolinska Institutet, Stockholm, Sweden
| | - Mara Mennuni
- Division of Molecular Metabolism, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden.,Max Planck Institute for Biology of Ageing - Karolinska Institutet Laboratory, Karolinska Institutet, Stockholm, Sweden
| | - David Alsina
- Division of Molecular Metabolism, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden.,Max Planck Institute for Biology of Ageing - Karolinska Institutet Laboratory, Karolinska Institutet, Stockholm, Sweden
| | - Nils-Göran Larsson
- Division of Molecular Metabolism, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden.,Max Planck Institute for Biology of Ageing - Karolinska Institutet Laboratory, Karolinska Institutet, Stockholm, Sweden
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12
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Parfenov AI, Krums LM, Bykova SV, Ahmadullina OV. [Chronic intestinal pseudo-obstruction]. TERAPEVT ARKH 2020; 92:4-9. [PMID: 33720566 DOI: 10.26442/00403660.2020.12.200426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/05/2021] [Indexed: 02/08/2023]
Abstract
Chronic intestinal pseudo-obstruction a rare violation of the motor skills of the gastrointestinal complex, similar to mechanical obstruction, but without a mechanical obstacle. The development of chronic intestinal pseudo-obstruction is caused by a disturbance on the part of the smooth muscles and the nervous system of the gastrointestinal system. Common symptoms include constipation, abdominal pain, nausea, vomiting, bloating. Violation of peristalsis leads to food stagnation in the hinges of the small intestine, their dilation, the development of bacterial insemination syndrome. Eating disorders, bacterial contamination syndrome (CDDs) lead to impaired suction syndrome, cahexia. Treatment is aimed at providing adequate nutrition, the use of drugs that activate motor skills, suppress the growth of microbes in the small intestine, the implementation of intestinal decompression. Surgical treatment: resection of the affected segment of the gut. In the refractory course of the disease intestinal transplantation.
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Affiliation(s)
| | - L M Krums
- Loginov Moscow Clinical Scientific Center
| | - S V Bykova
- Loginov Moscow Clinical Scientific Center
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13
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Saneto RP. Mitochondrial diseases: expanding the diagnosis in the era of genetic testing. JOURNAL OF TRANSLATIONAL GENETICS AND GENOMICS 2020; 4:384-428. [PMID: 33426505 PMCID: PMC7791531 DOI: 10.20517/jtgg.2020.40] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Mitochondrial diseases are clinically and genetically heterogeneous. These diseases were initially described a little over three decades ago. Limited diagnostic tools created disease descriptions based on clinical, biochemical analytes, neuroimaging, and muscle biopsy findings. This diagnostic mechanism continued to evolve detection of inherited oxidative phosphorylation disorders and expanded discovery of mitochondrial physiology over the next two decades. Limited genetic testing hampered the definitive diagnostic identification and breadth of diseases. Over the last decade, the development and incorporation of massive parallel sequencing has identified approximately 300 genes involved in mitochondrial disease. Gene testing has enlarged our understanding of how genetic defects lead to cellular dysfunction and disease. These findings have expanded the understanding of how mechanisms of mitochondrial physiology can induce dysfunction and disease, but the complete collection of disease-causing gene variants remains incomplete. This article reviews the developments in disease gene discovery and the incorporation of gene findings with mitochondrial physiology. This understanding is critical to the development of targeted therapies.
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Affiliation(s)
- Russell P. Saneto
- Center for Integrative Brain Research, Neuroscience Institute, Seattle, WA 98101, USA
- Department of Neurology/Division of Pediatric Neurology, Seattle Children’s Hospital/University of Washington, Seattle, WA 98105, USA
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14
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Hammans SR. Mitochondrial neurogastrointestinal encephalopathy disease (MNGIE). Pract Neurol 2020:practneurol-2020-002558. [PMID: 32980811 DOI: 10.1136/practneurol-2020-002558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 01/21/2023]
Abstract
Mitochondrial neurogastrointestinal encephalopathy (MNGIE) is a rare autosomal recessive condition. Deficiency of thymidine phosphorylase disrupts the nucleoside pool, with progressive secondary mitochondrial DNA damage. MNGIE is clinically diagnosable because of a distinctive tetrad of gastrointestinal dysmotility, progressive external ophthalmoplegia, demyelinating neuropathy and asymptomatic leucoencephalopathy. The diagnosis may be confirmed genetically or biochemically. Misdiagnosis is frequent, but early and accurate recognition allows the possibility of novel transplant therapies capable of rectifying the biochemical defects. Its management remains difficult in the face of progressive disability and the risks of treatment.
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Affiliation(s)
- Simon R Hammans
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Neurology, St Richards Hospital, Chichester, West Sussex, UK
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15
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Del Dotto V, Ullah F, Di Meo I, Magini P, Gusic M, Maresca A, Caporali L, Palombo F, Tagliavini F, Baugh EH, Macao B, Szilagyi Z, Peron C, Gustafson MA, Khan K, La Morgia C, Barboni P, Carbonelli M, Valentino ML, Liguori R, Shashi V, Sullivan J, Nagaraj S, El-Dairi M, Iannaccone A, Cutcutache I, Bertini E, Carrozzo R, Emma F, Diomedi-Camassei F, Zanna C, Armstrong M, Page M, Stong N, Boesch S, Kopajtich R, Wortmann S, Sperl W, Davis EE, Copeland WC, Seri M, Falkenberg M, Prokisch H, Katsanis N, Tiranti V, Pippucci T, Carelli V. SSBP1 mutations cause mtDNA depletion underlying a complex optic atrophy disorder. J Clin Invest 2020; 130:108-125. [PMID: 31550240 DOI: 10.1172/jci128514] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/19/2019] [Indexed: 01/07/2023] Open
Abstract
Inherited optic neuropathies include complex phenotypes, mostly driven by mitochondrial dysfunction. We report an optic atrophy spectrum disorder, including retinal macular dystrophy and kidney insufficiency leading to transplantation, associated with mitochondrial DNA (mtDNA) depletion without accumulation of multiple deletions. By whole-exome sequencing, we identified mutations affecting the mitochondrial single-strand binding protein (SSBP1) in 4 families with dominant and 1 with recessive inheritance. We show that SSBP1 mutations in patient-derived fibroblasts variably affect the amount of SSBP1 protein and alter multimer formation, but not the binding to ssDNA. SSBP1 mutations impaired mtDNA, nucleoids, and 7S-DNA amounts as well as mtDNA replication, affecting replisome machinery. The variable mtDNA depletion in cells was reflected in severity of mitochondrial dysfunction, including respiratory efficiency, OXPHOS subunits, and complex amount and assembly. mtDNA depletion and cytochrome c oxidase-negative cells were found ex vivo in biopsies of affected tissues, such as kidney and skeletal muscle. Reduced efficiency of mtDNA replication was also reproduced in vitro, confirming the pathogenic mechanism. Furthermore, ssbp1 suppression in zebrafish induced signs of nephropathy and reduced optic nerve size, the latter phenotype complemented by WT mRNA but not by SSBP1 mutant transcripts. This previously unrecognized disease of mtDNA maintenance implicates SSBP1 mutations as a cause of human pathology.
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Affiliation(s)
- Valentina Del Dotto
- Unit of Neurology, Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Farid Ullah
- Center for Human Disease Modeling, Duke University, Durham, North Carolina, USA.,Human Molecular Genetics Laboratory, Health Biotechnology Division, National Institute for Biotechnology and Genetic Engineering (NIBGE), Faisalabad, Pakistan.,Pakistan Institute of Engineering and Applied Sciences (PIEAS), Faisalabad, Pakistan
| | - Ivano Di Meo
- Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Pamela Magini
- Medical Genetics Unit, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mirjana Gusic
- Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany.,Institute of Human Genetics, Technische Universität München, Munich, Germany
| | - Alessandra Maresca
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Leonardo Caporali
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Flavia Palombo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Francesca Tagliavini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Evan Harris Baugh
- Institute for Genomic Medicine, Columbia University, New York, New York, USA
| | - Bertil Macao
- Department of Medical Biochemistry and Cell Biology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Zsolt Szilagyi
- Department of Medical Biochemistry and Cell Biology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Camille Peron
- Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Margaret A Gustafson
- Genome Integrity and Structural Biology Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Kamal Khan
- Center for Human Disease Modeling, Duke University, Durham, North Carolina, USA.,Human Molecular Genetics Laboratory, Health Biotechnology Division, National Institute for Biotechnology and Genetic Engineering (NIBGE), Faisalabad, Pakistan.,Pakistan Institute of Engineering and Applied Sciences (PIEAS), Faisalabad, Pakistan
| | - Chiara La Morgia
- Unit of Neurology, Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Piero Barboni
- Department of Ophthalmology, Studio Oculistico d'Azeglio, Bologna, Italy
| | - Michele Carbonelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Maria Lucia Valentino
- Unit of Neurology, Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Rocco Liguori
- Unit of Neurology, Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | | | | | - Shashi Nagaraj
- Division of Nephrology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Alessandro Iannaccone
- Center for Retinal Degenerations and Ophthalmic Genetic Diseases and Visual Function Diagnostic Laboratory, Duke Eye Center, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Enrico Bertini
- Unit of Muscular and Neurodegenerative Diseases, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rosalba Carrozzo
- Unit of Muscular and Neurodegenerative Diseases, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Emma
- Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Claudia Zanna
- Department of Pharmacy and Biotechnology (FABIT), University of Bologna, Bologna, Italy
| | | | - Matthew Page
- Translational Medicine, UCB Pharma, Slough, United Kingdom
| | - Nicholas Stong
- Institute for Genomic Medicine, Columbia University, New York, New York, USA
| | - Sylvia Boesch
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Robert Kopajtich
- Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany.,Institute of Human Genetics, Technische Universität München, Munich, Germany
| | - Saskia Wortmann
- Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany.,Institute of Human Genetics, Technische Universität München, Munich, Germany.,Department of Pediatrics, Salzburger Landeskliniken and Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Wolfgang Sperl
- Department of Pediatrics, Salzburger Landeskliniken and Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Erica E Davis
- Center for Human Disease Modeling, Duke University, Durham, North Carolina, USA
| | - William C Copeland
- Genome Integrity and Structural Biology Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Marco Seri
- Medical Genetics Unit, Sant'Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Maria Falkenberg
- Department of Medical Biochemistry and Cell Biology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Holger Prokisch
- Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany.,Institute of Human Genetics, Technische Universität München, Munich, Germany
| | - Nicholas Katsanis
- Center for Human Disease Modeling, Duke University, Durham, North Carolina, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Departments of Pediatrics and Cellular and Molecular Biology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Valeria Tiranti
- Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Tommaso Pippucci
- Medical Genetics Unit, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Valerio Carelli
- Unit of Neurology, Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
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16
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D'Angelo R, Boschetti E, Amore G, Costa R, Pugliese A, Caporali L, Gramegna LL, Papa V, Vizioli L, Capristo M, Contin M, Mohamed S, Cenacchi G, Lodi R, Morelli MC, Fasano L, Pisani L, Cescon M, Tonon C, Pinna AD, Dotti MT, Sicurelli F, Scarpelli M, Filosto M, Casali C, Pironi L, Carelli V, De Giorgio R, Rinaldi R. Liver transplantation in mitochondrial neurogastrointestinal encephalomyopathy (MNGIE): clinical long-term follow-up and pathogenic implications. J Neurol 2020; 267:3702-3710. [PMID: 32683607 DOI: 10.1007/s00415-020-10051-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 01/21/2023]
Abstract
We report the longest follow-up of clinical and biochemical features of two previously reported adult mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) patients treated with liver transplantation (LT), adding information on a third, recently transplanted, patient. All three patients overcame the early post-operative period and tolerated immunosuppressive therapy. Plasma nucleoside levels dramatically decreased, with evidence of clinical improvement of ambulation and neuropathy. Conversely, other features of MNGIE, as gastrointestinal dysmotility, low weight, ophthalmoparesis, and leukoencephalopathy were essentially unchanged. A similar picture characterized two patients treated with allogenic hematopoietic stem cell transplantation (AHSCT). In conclusion, LT promptly and stably normalizes nucleoside imbalance in MNGIE, stabilizing or improving some clinical parameters with marginal periprocedural mortality rate as compared to AHSCT. Nevertheless, restoring thymidine phosphorylase (TP) activity, achieved by both LT and AHSCT, does not allow a full clinical recovery, probably due to consolidated cellular damage and/or incomplete enzymatic tissue replacement.
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Affiliation(s)
- Roberto D'Angelo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Interaziendale Clinica Neurologica Rete Metropolitana (NeuroMet), Neurologia AOU S. Orsola-Malpighi, Policlinico Sant'Orsola-Malpighi, Building #2, Via Albertoni, 15, 40138, Bologna, Italy.
| | - Elisa Boschetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giulia Amore
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Roberta Costa
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Alessia Pugliese
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Leonardo Caporali
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Laura Ludovica Gramegna
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Valentina Papa
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Luca Vizioli
- Department of Organ Insufficiency and Transplantation, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mariantonietta Capristo
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Manuela Contin
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Susan Mohamed
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giovanna Cenacchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Raffaele Lodi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Maria Cristina Morelli
- Department of Organ Insufficiency and Transplantation, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Luca Fasano
- Respiratory and Critical Care Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Lara Pisani
- Respiratory and Critical Care Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Matteo Cescon
- Department of Organ Insufficiency and Transplantation, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Caterina Tonon
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Functional and Molecular Neuroimaging Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Antonio Daniele Pinna
- Department of Organ Insufficiency and Transplantation, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Maria Teresa Dotti
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Francesco Sicurelli
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | | | - Massimiliano Filosto
- Center for Neuromuscular Diseases, Unit of Neurology, ASST "Spedali Civili", Brescia, Italy
| | - Carlo Casali
- Department of Medico-Surgical Sciences and Biotechnologies, University 'La Sapienza', Roma, Italy
| | - Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Valerio Carelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Roberto De Giorgio
- Department of Morphology, Surgery and Experimental Medicine, St. Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Interaziendale Clinica Neurologica Rete Metropolitana (NeuroMet), Neurologia AOU S. Orsola-Malpighi, Policlinico Sant'Orsola-Malpighi, Building #2, Via Albertoni, 15, 40138, Bologna, Italy
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17
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Abstract
PURPOSE OF REVIEW Chronic intestinal pseudo-obstruction (CIPO) is the most severe and disabling form of gastrointestinal dysmotility characterized by an impairment of coordinated propulsive activity in the gastrointestinal tract mimicking mechanical intestinal obstruction. Over the last few years, major advances have been made in the diagnostic and therapeutic management of this rare disorder. RECENT FINDINGS The present narrative review aims to summarize the current literature about the management of CIPO focusing on significant novelties about definition, epidemiology, diagnosis, and therapeutic options. The most significant advancement is a consensus on classification and dedicated diagnostic criteria for CIPO in children highlighting the distinctive features between adult and pediatric forms of CIPO (hence pediatric intestinal pseudo-obstruction). Despite no single diagnostic test is pathognomonic of CIPO and no recommended drug treatment is advised to improve gastrointestinal motility, recent reports suggest promising results in both diagnostic testing and therapy that might assist the diagnosis and help the management of patients with CIPO. SUMMARY The articles referenced in this review will help in optimizing the clinical management of this rare and severe disease in adult population.
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18
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Nardi N, Proulx F, Brunel-Guiton C, Oligny LL, Piché N, Mitchell GA, Joyal JS. Fulminant Necrotizing Enterocolitis and Multiple Organ Dysfunction in a Toddler with Mitochondrial DNA Depletion Syndrome-13. J Pediatr Intensive Care 2019; 9:54-59. [PMID: 31984159 DOI: 10.1055/s-0039-1697620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 08/15/2019] [Indexed: 12/13/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is exceptional after the neonatal period. A toddler with encephalopathy, mitochondrial myopathy, and hypertrophic cardiomyopathy developed fatal NEC and multiple organ dysfunction within 48 hours of the introduction of enteral feeding. She was subsequently found to have pathogenic mutations in FBXL4 , a cause of mitochondrial DNA depletion syndrome-13. Intestinal dysmotility in the context of deficient mitochondrial respiration may have contributed to the development of NEC. Current paradigms call for early introduction of enteral nutrition to reinstate energy homeostasis. Enteral feeding should be administered with caution during metabolic crises of patients with mitochondrial DNA depletion syndromes.
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Affiliation(s)
- Nicolas Nardi
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Canada
| | - François Proulx
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Canada
| | | | - Luc L Oligny
- Department of Pediatric Pathology, Sainte-Justine Hospital, University of Montreal, Montreal, Canada
| | - Nelson Piché
- Department of Pediatric Surgery, Sainte-Justine Hospital, University of Montreal, Montreal, Canada
| | - Grant A Mitchell
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Canada
| | - Jean Sébastien Joyal
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Canada
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19
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Bax BE, Levene M, Bain MD, Fairbanks LD, Filosto M, Kalkan Uçar S, Klopstock T, Kornblum C, Mandel H, Rahman S, Roubertie A, Scarpelli M, Sedgwick PM, Baru M, Sellos-Moura M, Price J, Horn P, Nirmalananthan N. Erythrocyte Encapsulated Thymidine Phosphorylase for the Treatment of Patients with Mitochondrial Neurogastrointestinal Encephalomyopathy: Study Protocol for a Multi-Centre, Multiple Dose, Open Label Trial. J Clin Med 2019; 8:jcm8081096. [PMID: 31344955 PMCID: PMC6722784 DOI: 10.3390/jcm8081096] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/19/2019] [Accepted: 07/23/2019] [Indexed: 02/05/2023] Open
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an autosomal recessive disorder which primarily affects the gastrointestinal and nervous systems. This disease is caused by mutations in the nuclear TYMP gene, which encodes for thymidine phosphorylase, an enzyme required for the normal metabolism of deoxynucleosides, thymidine, and deoxyuridine. The subsequent elevated systemic concentrations of deoxynucleosides lead to increased intracellular concentrations of their corresponding triphosphates, and ultimately mitochondrial failure due to progressive accumulation of mitochondrial DNA (mtDNA) defects and mtDNA depletion. Currently, there are no treatments for MNGIE where effectiveness has been evidenced in clinical trials. This Phase 2, multi-centre, multiple dose, open label trial without a control will investigate the application of erythrocyte-encapsulated thymidine phosphorylase (EE-TP) as an enzyme replacement therapy for MNGIE. Three EE-TP dose levels are planned with patients receiving the dose level that achieves metabolic correction. The study duration is 31 months, comprising 28 days of screening, 90 days of run-in, 24 months of treatment and 90 days of post-dose follow-up. The primary objectives are to determine the safety, tolerability, pharmacodynamics, and efficacy of multiple doses of EE-TP. The secondary objectives are to assess EE-TP immunogenicity after multiple dose administrations and changes in clinical assessments, and the pharmacodynamics effect of EE-TP on clinical assessments.
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Affiliation(s)
- Bridget E Bax
- Molecular and Clinical Sciences, St. George's, University of London, London SW17 0RE, UK.
| | - Michelle Levene
- Molecular and Clinical Sciences, St. George's, University of London, London SW17 0RE, UK
| | - Murray D Bain
- Molecular and Clinical Sciences, St. George's, University of London, London SW17 0RE, UK
| | | | - Massimiliano Filosto
- Centre for Neuromuscular Diseases, ASST Spedali Civili and University of Brescia, 25100 Brescia, Italy
| | - Sema Kalkan Uçar
- Division of Inborn Error of Metabolism, Ege University Medical Faculty, 35100 Izmir, Turkey
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, University of Munich, Ziemssenstr. 1, 80336 Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Ludwig Maximilians University, Geschwister-Scholl-Platz 1, 80539 Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Feodor-Lynen-Strasse 17, 81377 Munich, Germany
| | - Cornelia Kornblum
- Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | | | - Shamima Rahman
- Mitochondrial Research Group, UCL London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Metabolic Unit, Great Ormond Street Hospital NHS Foundation Trust, London WC1N 3JH, UK
| | - Agathe Roubertie
- Department of Pediatric Neurology, Centre Hospitalier Universitaire de Montpellier, 34295 Montpellier, France
| | - Mauro Scarpelli
- Institute of Neurology, University of Verona, 37126 Verona, Italy
| | - Philip M Sedgwick
- Institute for Medical and Biomedical Education, St George's, University of London, London SW17 0RE, UK
| | - Moshe Baru
- Orphan Technologies, Zürcherstrasse 19, 8640 Rapperswil, Switzerland
| | | | - Jeanie Price
- Orphan Technologies, Zürcherstrasse 19, 8640 Rapperswil, Switzerland
| | | | - Niranjanan Nirmalananthan
- Molecular and Clinical Sciences, St. George's, University of London, London SW17 0RE, UK
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
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20
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Yadak R, Breur M, Bugiani M. Gastrointestinal Dysmotility in MNGIE: from thymidine phosphorylase enzyme deficiency to altered interstitial cells of Cajal. Orphanet J Rare Dis 2019; 14:33. [PMID: 30736844 PMCID: PMC6368792 DOI: 10.1186/s13023-019-1016-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/31/2019] [Indexed: 12/24/2022] Open
Abstract
Background MNGIE is a rare and fatal disease in which absence of the enzyme thymidine phosphorylase induces systemic accumulation of thymidine and deoxyuridine and secondary mitochondrial DNA alterations. Gastrointestinal (GI) symptoms are frequently reported in MNGIE patients, however, they are not resolved with the current treatment interventions. Recently, our understanding of the GI pathology has increased, which rationalizes the pursuit of more targeted therapeutic strategies. In particular, interstitial cells of Cajal (ICC) play key roles in GI physiology and are involved in the pathogenesis of the GI dysmotility. However, understanding of the triggers of ICC deficits in MNGIE is lacking. Herein, we review the current knowledge about the pathology of GI dysmotility in MNGIE, discuss potential mechanisms in relation to ICC loss/dysfunction, remark on the limited contribution of the current treatments, and propose intervention strategies to overcome ICC deficits. Finally, we address the advances and new research avenues offered by organoids and tissue engineering technologies, and propose schemes to implement to further our understanding of the GI pathology and utility in regenerative and personalized medicine in MNGIE. Conclusion Interstitial cells of Cajal play key roles in the physiology of the gastrointestinal motility. Evaluation of their status in the GI dysmotility related to MNGIE would be valuable for diagnosis of MNGIE. Understanding the underlying pathological and molecular mechanisms affecting ICC is an asset for the development of targeted prevention and treatment strategies for the GI dysmotility related to MNGIE.
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Affiliation(s)
- Rana Yadak
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Marjolein Breur
- Department of Child Neurology, VU University Medical center, Amsterdam, The Netherlands
| | - Marianna Bugiani
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands.
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21
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Patel R, Coulter LL, Rimmer J, Parkes M, Chinnery PF, Swift O. Mitochondrial neurogastrointestinal encephalopathy: a clinicopathological mimic of Crohn's disease. BMC Gastroenterol 2019; 19:11. [PMID: 30646848 PMCID: PMC6334462 DOI: 10.1186/s12876-018-0925-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 12/25/2018] [Indexed: 01/09/2023] Open
Abstract
Background Mitochondrial neurogastrointestinal encephalopathy (MNGIE), due to mutations in TYMP, often presents with gastrointestinal symptoms. Two sisters, initially managed for Crohn’s disease based upon clinical, imaging and pathological findings, were later found to have MNGIE. The cases provide novel clinicopathological insight, for two further reasons: both sisters remain ambulant and in employment in their late 20s and 30s; diagnosis in one sister was made after a suspected azathioprine-precipitated acute illness. Case presentation A 25-year-old female presented with diarrhoea, vomiting, abdominal pain, and bloating. Faecal calprotectin, colonic biopsies and magnetic resonance enterography were consistent with a diagnosis of Crohn’s disease. Azathioprine initiation preceded admission with a sore throat, headache, myalgia, and pyrexia. Withdrawal led to rapid clinical improvement. MRI brain revealed persistent, extensive white matter changes. Elevated plasma and urine thymidine and deoxyuridine, and genetic testing for TYMP variants, confirmed MNGIE. Testing of the patient’s sister, also diagnosed with Crohn’s disease, revealed identical variants. In this context, retrospective review of colonic biopsies identified histological findings suggestive of MNGIE. Conclusions Azathioprine interference in nucleic acid metabolism may interact with the mitochondrial DNA depletion of MNGIE. Nucleotide supplementation, proposed for treatment by manipulating mitochondrial nucleoside pools, may require caution. The late onset and mild phenotype observed confirms presentation can occur later in life, and may reflect residual thymidine phosphorylase activity. Clinicians should consider measuring plasma thymidine levels in suspected Crohn’s disease to rule out MNGIE, particularly if white matter abnormalities are identified on neuroimaging.
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Affiliation(s)
- Ravi Patel
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - Lucia Lee Coulter
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SP, UK
| | - Joanna Rimmer
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Miles Parkes
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Patrick Francis Chinnery
- MRC Mitochondrial Biology Unit, University of Cambridge, Wellcome Trust / MRC Building, Cambridge Biomedical Campus Hills Road, Cambridge, CB2 0XY, UK. .,Department of Clinical Neurosciences, University of Cambridge, Biomedical Campus, Cambridge, CB2 0QQ, UK.
| | - Oscar Swift
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
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22
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Pacitti D, Levene M, Garone C, Nirmalananthan N, Bax BE. Mitochondrial Neurogastrointestinal Encephalomyopathy: Into the Fourth Decade, What We Have Learned So Far. Front Genet 2018; 9:669. [PMID: 30627136 PMCID: PMC6309918 DOI: 10.3389/fgene.2018.00669] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 12/04/2018] [Indexed: 02/05/2023] Open
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an ultra-rare metabolic autosomal recessive disease, caused by mutations in the nuclear gene TYMP which encodes the enzyme thymidine phosphorylase. The resulting enzyme deficiency leads to a systemic accumulation of the deoxyribonucleosides thymidine and deoxyuridine, and ultimately mitochondrial failure due to a progressive acquisition of secondary mitochondrial DNA (mtDNA) mutations and mtDNA depletion. Clinically, MNGIE is characterized by gastrointestinal and neurological manifestations, including cachexia, gastrointestinal dysmotility, peripheral neuropathy, leukoencephalopathy, ophthalmoplegia and ptosis. The disease is progressively degenerative and leads to death at an average age of 37.6 years. As with the vast majority of rare diseases, patients with MNGIE face a number of unmet needs related to diagnostic delays, a lack of approved therapies, and non-specific clinical management. We provide here a comprehensive collation of the available knowledge of MNGIE since the disease was first described 42 years ago. This review includes symptomatology, diagnostic procedures and hurdles, in vitro and in vivo disease models that have enhanced our understanding of the disease pathology, and finally experimental therapeutic approaches under development. The ultimate aim of this review is to increase clinical awareness of MNGIE, thereby reducing diagnostic delay and improving patient access to putative treatments under investigation.
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Affiliation(s)
- Dario Pacitti
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Michelle Levene
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Caterina Garone
- MRC Mitochondrial Biology Unit, Cambridge Biomedical, Cambridge, United Kingdom
| | | | - Bridget E. Bax
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
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23
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Spagnoli C, Pisani F, Di Mario F, Leandro G, Gaiani F, De' Angelis GL, Fusco C. Peripheral neuropathy and gastroenterologic disorders: an overview on an underrecognized association. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:22-32. [PMID: 30561392 PMCID: PMC6502186 DOI: 10.23750/abm.v89i9-s.7956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM OF THE WORK Although peripheral neuropathies in children are often of genetic origin, acquired causes should be carefully looked for and ruled out also in the pediatric age. Gastroenterological disorders can be complicated by peripheral neuropathy as a result of micronutrients deficiency, drug toxicity or because of shared pathophysiological mechanisms. METHODS In this descriptive review we sought to give an overview on the most relevant clinical conditions in which peripheral neuropathies are associated with gastro-intestinal disorders or symptoms. RESULTS We describe the clinical, demographic, and electrophysiological features of peripheral neuropathy in three main clinical scenarios: in the context of common gastroenterological disorders (inflammatory bowel and celiac disease), in the context of micronutrients deficiencies arising from malabsorption irrespective of etiology, and in a rare degenerative mitochondrial disorder, mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) disorder. CONCLUSIONS The association between gastrointestinal and peripheral nervous system symptoms is probably still underrecognized but has to be actively sought, in order to provide prompt diagnosis resulting in optimal care and long-term management with the aim to improve quality of life and, at least in some conditions, try to impact on prognosis.
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Affiliation(s)
- Carlotta Spagnoli
- Child Neurology Unit, Azienda USL- IRCCS di Reggio Emilia, Reggio Emilia, Italy.
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24
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A mitochondrial neurogastrointestinal encephalomyopathy with intestinal pseudo-obstruction resulted from a novel splice site mutation. Clin Dysmorphol 2018; 28:22-25. [PMID: 30407211 DOI: 10.1097/mcd.0000000000000250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Mitochondrial neurogastrointestinal encephalopathy (MNGIE) is an autosomal recessive disorder characterized by gastrointestinal dysmotility, cachexia, ptosis, peripheral neuropathy and leukoencephalopathy. The diagnosis is often not made until 5-10 years after the onset of symptoms. MNGIE is caused by mutations in thymidine phosphorylase gene TYMP. Here, we present a 19-year-old boy with MNGIE who had a chronic intestinal pseudo-obstruction, and we describe his family history. Genetic analysis revealed a novel homozygous c.765+1G>C intronic mutation which is expected to disrupt splicing of TYMP in the patient. Family screening revealed that the brother was also affected and the mother was a carrier. MNGIE should be considered and genetic testing instigated if individuals with cachexia have neuromuscular complaints or symptoms of chronic intestinal pseudo-obstruction.
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25
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Filosto M, Cotti Piccinelli S, Caria F, Gallo Cassarino S, Baldelli E, Galvagni A, Volonghi I, Scarpelli M, Padovani A. Mitochondrial Neurogastrointestinal Encephalomyopathy (MNGIE-MTDPS1). J Clin Med 2018; 7:jcm7110389. [PMID: 30373120 PMCID: PMC6262582 DOI: 10.3390/jcm7110389] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/14/2018] [Accepted: 10/24/2018] [Indexed: 12/12/2022] Open
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE-MTDPS1) is a devastating autosomal recessive disorder due to mutations in TYMP, which cause a loss of function of thymidine phosphorylase (TP), nucleoside accumulation in plasma and tissues, and mitochondrial dysfunction. The clinical picture includes progressive gastrointestinal dysmotility, cachexia, ptosis and ophthalmoparesis, peripheral neuropathy, and diffuse leukoencephalopathy, which usually lead to death in early adulthood. Other two MNGIE-type phenotypes have been described so far, which are linked to mutations in POLG and RRM2B genes. Therapeutic options are currently available in clinical practice (allogeneic hematopoietic stem cell transplantation and carrier erythrocyte entrapped thymidine phosphorylase therapy) and newer, promising therapies are expected in the near future. Since successful treatment is strictly related to early diagnosis, it is essential that clinicians be warned about the clinical features and diagnostic procedures useful to suspect diagnosis of MNGIE-MTDPS1. The aim of this review is to promote the knowledge of the disease as well as the involved mechanisms and the diagnostic processes in order to reach an early diagnosis.
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Affiliation(s)
- Massimiliano Filosto
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, 25100 Brescia, Italy.
| | - Stefano Cotti Piccinelli
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, 25100 Brescia, Italy.
| | - Filomena Caria
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, 25100 Brescia, Italy.
| | - Serena Gallo Cassarino
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, 25100 Brescia, Italy.
| | - Enrico Baldelli
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, 25100 Brescia, Italy.
| | - Anna Galvagni
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, 25100 Brescia, Italy.
| | - Irene Volonghi
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, 25100 Brescia, Italy.
| | - Mauro Scarpelli
- Department of Neuroscience, Unit of Neurology, Azienda Ospedaliera Universitaria Integrata Verona, 37100 Verona, Italy.
| | - Alessandro Padovani
- Center for Neuromuscular Diseases, Unit of Neurology, ASST Spedali Civili and University of Brescia, 25100 Brescia, Italy.
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26
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Yadak R, Boot MV, van Til NP, Cazals-Hatem D, Finkenstedt A, Bogaerts E, de Coo IF, Bugiani M. Transplantation, gene therapy and intestinal pathology in MNGIE patients and mice. BMC Gastroenterol 2018; 18:149. [PMID: 30340467 PMCID: PMC6194683 DOI: 10.1186/s12876-018-0881-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 10/10/2018] [Indexed: 12/29/2022] Open
Abstract
Background Gastrointestinal complications are the main cause of death in patients with mitochondrial neurogastrointestinal encephalomyopathy (MNGIE). Available treatments often restore biochemical homeostasis, but fail to cure gastrointestinal symptoms. Methods We evaluated the small intestine neuromuscular pathology of an untreated MNGIE patient and two recipients of hematopoietic stem cells, focusing on enteric neurons and glia. Additionally, we evaluated the intestinal neuromuscular pathology in a mouse model of MNGIE treated with hematopoietic stem cell gene therapy. Quantification of muscle wall thickness and ganglion cell density was performed blind to the genotype with ImageJ. Significance of differences between groups was determined by two-tailed Mann-Whitney U test (P < 0.05). Results Our data confirm that MNGIE presents with muscle atrophy and loss of Cajal cells and CD117/c-kit immunoreactivity in the small intestine. We also show that hematopoietic stem cell transplantation does not benefit human intestinal pathology at least on short-term. Conclusions We suggest that hematopoietic stem cell transplantation may be insufficient to restore intestinal neuropathology, especially at later stages of MNGIE. As interstitial Cajal cells and their networks play a key role in development of gastrointestinal dysmotility, alternative therapeutic approaches taking absence of these cells into account could be required.
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Affiliation(s)
- Rana Yadak
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Max V Boot
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
| | - Niek P van Til
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Armin Finkenstedt
- Department of Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Elly Bogaerts
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Irenaeus F de Coo
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marianna Bugiani
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands.
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27
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Paediatric Intestinal Pseudo-obstruction: Evidence and Consensus-based Recommendations From an ESPGHAN-Led Expert Group. J Pediatr Gastroenterol Nutr 2018; 66:991-1019. [PMID: 29570554 DOI: 10.1097/mpg.0000000000001982] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Chronic intestinal pseudo-obstructive (CIPO) conditions are considered the most severe disorders of gut motility. They continue to present significant challenges in clinical care despite considerable recent progress in our understanding of pathophysiology, resulting in unacceptable levels of morbidity and mortality. Major contributors to the disappointing lack of progress in paediatric CIPO include a dearth of clarity and uniformity across all aspects of clinical care from definition and diagnosis to management. In order to assist medical care providers in identifying, evaluating, and managing children with CIPO, experts in this condition within the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition as well as selected external experts, were charged with the task of developing a uniform document of evidence- and consensus-based recommendations. METHODS Ten clinically relevant questions addressing terminology, diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to June 2017 using a number of established electronic databases as well as repositories. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to evaluate outcome measures for the research questions. Levels of evidence and quality of evidence were assessed using the classification system of the Oxford Centre for Evidence-Based Medicine (diagnosis) and the GRADE system (treatment). Each of the recommendations were discussed, finalized, and voted upon using the nominal voting technique to obtain consensus. RESULTS This evidence- and consensus-based position paper provides recommendations specifically for chronic intestinal pseudo-obstruction in infants and children. It proposes these be termed paediatric intestinal pseudo-obstructive (PIPO) disorders to distinguish them from adult onset CIPO. The manuscript provides guidance on the diagnosis, evaluation, and treatment of children with PIPO in an effort to standardise the quality of clinical care and improve short- and long-term outcomes. Key recommendations include the development of specific diagnostic criteria for PIPO, red flags to alert clinicians to the diagnosis and guidance on the use of available investigative modalities. The group advocates early collaboration with expert centres where structured diagnosis and management is guided by a multi-disciplinary team, and include targeted nutritional, medical, and surgical interventions as well as transition to adult services. CONCLUSIONS This document is intended to be used in daily practice from the time of first presentation and definitive diagnosis PIPO through to the complex management and treatment interventions such as intestinal transplantation. Significant challenges remain to be addressed through collaborative clinical and research interactions.
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28
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Houghton D, Stewart CJ, Stamp C, Nelson A, Aj ami NJ, Petrosino JF, Wipat A, Trenell MI, Turnbull DM, Greaves LC. Impact of Age-Related Mitochondrial Dysfunction and Exercise on Intestinal Microbiota Composition. J Gerontol A Biol Sci Med Sci 2018; 73:571-578. [PMID: 29045670 PMCID: PMC5905657 DOI: 10.1093/gerona/glx197] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 10/13/2017] [Indexed: 12/21/2022] Open
Abstract
Mitochondrial dysfunction is prevalent in the aging gastrointestinal tract. We investigated whether mitochondrial function in aging colonic crypts and exercise influences microbial gut communities in mice. Twelve PolgAmut/mut mice were randomly divided into a sedentary and exercise group at 4 months. Seven-aged matched PolgA+/+ mice remained sedentary throughout. Stool samples were collected at 4, 7, and 11 months, and bacterial profiling was achieved through 16S rRNA sequencing profiling. Mitochondrial enzyme activity was assessed in colonic epithelial crypts at 11 months for PolgAmut/mut and PolgA+/+ mice. Sedentary and exercised PolgAmut/mut mice had significantly higher levels of mitochondrial dysfunction than PolgA+/+ mice (78%, 77%, and 1% of crypts, respectively). Bacterial profiles of sedentary PolgAmut/mut mice were significantly different from the sedentary PolgA+/+ mice, with increases in Lactobacillus and Mycoplasma, and decreases in Alistipes, Odoribacter, Anaeroplasma, Rikenella, Parabacteroides, and Allobaculum in the PolgAmut/mut mice. Exercise did not have any impact upon gut mitochondrial dysfunction; however, exercise did increase gut microbiota diversity and significantly increased bacterial genera Mucispirillum and Desulfovibrio. Mitochondrial dysfunction is associated with changes in the gut microbiota. Endurance exercise moderated some of these changes, establishing that environmental factors can influence gut microbiota, despite mitochondrial dysfunction.
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Affiliation(s)
- David Houghton
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher J Stewart
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, Texas
| | - Craig Stamp
- Wellcome Trust Centre for Mitochondrial Research, Institute for Cell and Molecular Biosciences and Institute of Neuroscience, Medical School, Newcastle University, Newcastle upon Tyne
| | - Andrew Nelson
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne
| | - Nadim J Aj ami
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, Texas
| | - Joseph F Petrosino
- Department of Molecular Virology and Microbiology, Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, Texas
| | - Anil Wipat
- School of Computing Science, Newcastle University, Newcastle upon Tyne
| | - Michael I Trenell
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- LLHW Newcastle University Centre for Ageing and Vitality, Faculty of Medicine, Newcastle upon Tyne, UK
| | - Douglass M Turnbull
- Wellcome Trust Centre for Mitochondrial Research, Institute for Cell and Molecular Biosciences and Institute of Neuroscience, Medical School, Newcastle University, Newcastle upon Tyne
- LLHW Newcastle University Centre for Ageing and Vitality, Faculty of Medicine, Newcastle upon Tyne, UK
| | - Laura C Greaves
- Wellcome Trust Centre for Mitochondrial Research, Institute for Cell and Molecular Biosciences and Institute of Neuroscience, Medical School, Newcastle University, Newcastle upon Tyne
- LLHW Newcastle University Centre for Ageing and Vitality, Faculty of Medicine, Newcastle upon Tyne, UK
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29
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Gramegna LL, Pisano A, Testa C, Manners DN, D'Angelo R, Boschetti E, Giancola F, Pironi L, Caporali L, Capristo M, Valentino ML, Plazzi G, Casali C, Dotti MT, Cenacchi G, Hirano M, Giordano C, Parchi P, Rinaldi R, De Giorgio R, Lodi R, Carelli V, Tonon C. Cerebral Mitochondrial Microangiopathy Leads to Leukoencephalopathy in Mitochondrial Neurogastrointestinal Encephalopathy. AJNR Am J Neuroradiol 2018; 39:427-434. [PMID: 29348134 DOI: 10.3174/ajnr.a5507] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 10/30/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Mitochondrial neurogastrointestinal encephalopathy is a rare disorder due to recessive mutations in the thymidine phosphorylase gene, encoding thymidine phosphorylase protein required for mitochondrial DNA replication. Clinical manifestations include gastrointestinal dysmotility and diffuse asymptomatic leukoencephalopathy. This study aimed to elucidate the mechanisms underlying brain leukoencephalopathy in patients with mitochondrial neurogastrointestinal encephalopathy by correlating multimodal neuroradiologic features to postmortem pathology. MATERIALS AND METHODS Seven patients underwent brain MR imaging, including single-voxel proton MR spectroscopy and diffusion imaging. Absolute concentrations of metabolites calculated by acquiring unsuppressed water spectra at multiple TEs, along with diffusion metrics based on the tensor model, were compared with those of healthy controls using unpaired t tests in multiple white matters regions. Brain postmortem histologic, immunohistochemical, and molecular analyses were performed in 1 patient. RESULTS All patients showed bilateral and nearly symmetric cerebral white matter hyperintensities on T2-weighted images, extending to the cerebellar white matter and brain stem in 4. White matter, N-acetylaspartate, creatine, and choline concentrations were significantly reduced compared with those in controls, with a prominent increase in the radial water diffusivity component. At postmortem examination, severe fibrosis of brain vessel smooth muscle was evident, along with mitochondrial DNA replication depletion in brain and vascular smooth-muscle and endothelial cells, without neuronal loss, myelin damage, or gliosis. Prominent periependymal cytochrome C oxidase deficiency was also observed. CONCLUSIONS Vascular functional and histologic alterations account for leukoencephalopathy in mitochondrial neurogastrointestinal encephalopathy. Thymidine toxicity and mitochondrial DNA replication depletion may induce microangiopathy and blood-brain-barrier dysfunction, leading to increased water content in the white matter. Periependymal cytochrome C oxidase deficiency could explain prominent periventricular impairment.
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Affiliation(s)
- L L Gramegna
- From the Functional MR Unit (L.L.G., C.T., D.N.M., R.L., C.T.).,Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.)
| | - A Pisano
- Departments of Radiology, Oncology, and Pathology (A.P., C.G.)
| | - C Testa
- From the Functional MR Unit (L.L.G., C.T., D.N.M., R.L., C.T.).,Neurology Unit (R.D., R.R.), S.Orsola-Malpighi Hospital, Bologna, Italy.,Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.)
| | - D N Manners
- From the Functional MR Unit (L.L.G., C.T., D.N.M., R.L., C.T.).,Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.)
| | - R D'Angelo
- Neurology Unit (R.D., R.R.), S.Orsola-Malpighi Hospital, Bologna, Italy
| | - E Boschetti
- Surgical and Medical Sciences (E.B., F.G., L.P., R.D.G.), University of Bologna, Bologna, Italy
| | - F Giancola
- Surgical and Medical Sciences (E.B., F.G., L.P., R.D.G.), University of Bologna, Bologna, Italy
| | - L Pironi
- Surgical and Medical Sciences (E.B., F.G., L.P., R.D.G.), University of Bologna, Bologna, Italy
| | - L Caporali
- Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.).,Istituto di Ricovero e Cura a Carattere Scientifico Institute of Neurological Sciences (L.C., M.C., M.L.V., G.P., P.P., V.C.), Bologna, Italy
| | - M Capristo
- Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.).,Istituto di Ricovero e Cura a Carattere Scientifico Institute of Neurological Sciences (L.C., M.C., M.L.V., G.P., P.P., V.C.), Bologna, Italy
| | - M L Valentino
- Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.).,Istituto di Ricovero e Cura a Carattere Scientifico Institute of Neurological Sciences (L.C., M.C., M.L.V., G.P., P.P., V.C.), Bologna, Italy
| | - G Plazzi
- Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.).,Istituto di Ricovero e Cura a Carattere Scientifico Institute of Neurological Sciences (L.C., M.C., M.L.V., G.P., P.P., V.C.), Bologna, Italy
| | - C Casali
- Medico-Surgical Sciences and Biotechnologies (C.C.), Sapienza, University of Rome, Rome, Italy
| | - M T Dotti
- Department of Medicine, Surgery, and Neuroscience (M.T.D.), University of Siena, Siena, Italy
| | - G Cenacchi
- Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.)
| | - M Hirano
- Department of Neurology (M.H.), Columbia University Medical Centre, New York, New York
| | - C Giordano
- Departments of Radiology, Oncology, and Pathology (A.P., C.G.)
| | - P Parchi
- Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.).,Istituto di Ricovero e Cura a Carattere Scientifico Institute of Neurological Sciences (L.C., M.C., M.L.V., G.P., P.P., V.C.), Bologna, Italy
| | - R Rinaldi
- Neurology Unit (R.D., R.R.), S.Orsola-Malpighi Hospital, Bologna, Italy
| | - R De Giorgio
- Surgical and Medical Sciences (E.B., F.G., L.P., R.D.G.), University of Bologna, Bologna, Italy
| | - R Lodi
- From the Functional MR Unit (L.L.G., C.T., D.N.M., R.L., C.T.) .,Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.)
| | - V Carelli
- Departments of Biomedical and Neuromotor Sciences (L.L.G., C.T., D.N.M., L.C., M.C., M.L.V., G.P., G.C., P.P., R.L., V.C., C.T.).,Istituto di Ricovero e Cura a Carattere Scientifico Institute of Neurological Sciences (L.C., M.C., M.L.V., G.P., P.P., V.C.), Bologna, Italy
| | - C Tonon
- From the Functional MR Unit (L.L.G., C.T., D.N.M., R.L., C.T.)
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30
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Imperatore N, Tortora R, Gerbino N, Caporaso N, Rispo A. Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) mimicking refractory celiac disease. Dig Liver Dis 2017; 49:1061-1062. [PMID: 28539227 DOI: 10.1016/j.dld.2017.04.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 04/23/2017] [Accepted: 04/24/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Nicola Imperatore
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine "Federico II" of Naples, Italy.
| | - Raffaella Tortora
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine "Federico II" of Naples, Italy
| | - Nicolò Gerbino
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine "Federico II" of Naples, Italy
| | - Nicola Caporaso
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine "Federico II" of Naples, Italy
| | - Antonio Rispo
- Gastroenterology, Department of Clinical Medicine and Surgery, School of Medicine "Federico II" of Naples, Italy
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31
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Viscomi C, Zeviani M. MtDNA-maintenance defects: syndromes and genes. J Inherit Metab Dis 2017; 40:587-599. [PMID: 28324239 PMCID: PMC5500664 DOI: 10.1007/s10545-017-0027-5] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 02/02/2023]
Abstract
A large group of mitochondrial disorders, ranging from early-onset pediatric encephalopathic syndromes to late-onset myopathy with chronic progressive external ophthalmoplegia (CPEOs), are inherited as Mendelian disorders characterized by disturbed mitochondrial DNA (mtDNA) maintenance. These errors of nuclear-mitochondrial intergenomic signaling may lead to mtDNA depletion, accumulation of mtDNA multiple deletions, or both, in critical tissues. The genes involved encode proteins belonging to at least three pathways: mtDNA replication and maintenance, nucleotide supply and balance, and mitochondrial dynamics and quality control. In most cases, allelic mutations in these genes may lead to profoundly different phenotypes associated with either mtDNA depletion or multiple deletions.
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Affiliation(s)
- Carlo Viscomi
- MRC-Mitochondrial Biology Unit, MRC MBU, Wellcome Trust/MRC Building, Hills Road, Cambridge, CB2 0XY, UK
| | - Massimo Zeviani
- MRC-Mitochondrial Biology Unit, MRC MBU, Wellcome Trust/MRC Building, Hills Road, Cambridge, CB2 0XY, UK.
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32
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Yadak R, Sillevis Smitt P, van Gisbergen MW, van Til NP, de Coo IFM. Mitochondrial Neurogastrointestinal Encephalomyopathy Caused by Thymidine Phosphorylase Enzyme Deficiency: From Pathogenesis to Emerging Therapeutic Options. Front Cell Neurosci 2017; 11:31. [PMID: 28261062 PMCID: PMC5309216 DOI: 10.3389/fncel.2017.00031] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/01/2017] [Indexed: 01/05/2023] Open
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a progressive metabolic disorder caused by thymidine phosphorylase (TP) enzyme deficiency. The lack of TP results in systemic accumulation of deoxyribonucleosides thymidine (dThd) and deoxyuridine (dUrd). In these patients, clinical features include mental regression, ophthalmoplegia, and fatal gastrointestinal complications. The accumulation of nucleosides also causes imbalances in mitochondrial DNA (mtDNA) deoxyribonucleoside triphosphates (dNTPs), which may play a direct or indirect role in the mtDNA depletion/deletion abnormalities, although the exact underlying mechanism remains unknown. The available therapeutic approaches include dialysis and enzyme replacement therapy, both can only transiently reverse the biochemical imbalance. Allogeneic hematopoietic stem cell transplantation is shown to be able to restore normal enzyme activity and improve clinical manifestations in MNGIE patients. However, transplant related complications and disease progression result in a high mortality rate. New therapeutic approaches, such as adeno-associated viral vector and hematopoietic stem cell gene therapy have been tested in Tymp-/-Upp1-/- mice, a murine model for MNGIE. This review provides background information on disease manifestations of MNGIE with a focus on current management and treatment options. It also outlines the pre-clinical approaches toward future treatment of the disease.
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Affiliation(s)
- Rana Yadak
- Department of Neurology, Erasmus University Medical Center Rotterdam, Netherlands
| | - Peter Sillevis Smitt
- Department of Neurology, Erasmus University Medical Center Rotterdam, Netherlands
| | - Marike W van Gisbergen
- Department of Radiation Oncology (MaastRO-Lab), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre Maastricht, Netherlands
| | - Niek P van Til
- Laboratory of Translational Immunology, University Medical Center Utrecht Utrecht, Netherlands
| | - Irenaeus F M de Coo
- Department of Neurology, Erasmus University Medical Center Rotterdam, Netherlands
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33
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Di Nardo G, Di Lorenzo C, Lauro A, Stanghellini V, Thapar N, Karunaratne TB, Volta U, De Giorgio R. Chronic intestinal pseudo-obstruction in children and adults: diagnosis and therapeutic options. Neurogastroenterol Motil 2017; 29. [PMID: 27683196 DOI: 10.1111/nmo.12945] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) represents the most severe form of gastrointestinal dysmotility with debilitating and potentially lethal consequences. Symptoms can be non-specific, and result in this condition being diagnosed incorrectly or too late with consequences for morbidity and even mortality. PURPOSE The present article aims to provide pediatric and adult gastroenterologists with an up to date review about clinical features, diagnosis and therapeutic options for CIPO. Although pediatric and adult CIPO share many clinical aspects distinctive features can be identified. There is no single diagnostic test or pathognomonic finding of CIPO, thus a stepwise approach including radiology, endoscopy, laboratory, manometry, and histopathology should be considered in the diagnostic work-up. Treatment of patients with CIPO is challenging and requires a multidisciplinary effort with participation of appropriately experienced gastroenterologists, pathologists, dieticians, surgeons, psychologists, and other subspecialists based on the presence of comorbidities. Current treatment options invariably involve surgery and specialized nutritional support, especially in children. Medical therapies are mainly aimed to avoid complications such as sepsis or intestinal bacterial overgrowth and, where possible, restore intestinal propulsion. More efficacious therapeutic options are eagerly awaited for such difficult patients.
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Affiliation(s)
- G Di Nardo
- Pediatric Unit, Orvieto Hospital, Orvieto, Italy.,Pediatric Gastroenterology Unit, International Hospital Salvator Mundi, Rome, Italy
| | - C Di Lorenzo
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - A Lauro
- Liver and Multiorgan Transplant Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - V Stanghellini
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - N Thapar
- Department of Gastroenterology, Great Ormond Street Hospital, Institute of Child Health, London, UK
| | - T B Karunaratne
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - U Volta
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - R De Giorgio
- Department of Medical and Surgical Sciences, Centro di Ricerca BioMedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
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34
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De Giorgio R, Pironi L, Rinaldi R, Boschetti E, Caporali L, Capristo M, Casali C, Cenacchi G, Contin M, D'Angelo R, D'Errico A, Gramegna LL, Lodi R, Maresca A, Mohamed S, Morelli MC, Papa V, Tonon C, Tugnoli V, Carelli V, D'Alessandro R, Pinna AD. Liver transplantation for mitochondrial neurogastrointestinal encephalomyopathy. Ann Neurol 2016; 80:448-455. [DOI: 10.1002/ana.24724] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Roberto De Giorgio
- Department of Surgical and Medical SciencesUniversity of BolognaBologna Italy
| | - Loris Pironi
- Department of Surgical and Medical SciencesUniversity of BolognaBologna Italy
| | - Rita Rinaldi
- Neurology UnitSt. Orsola‐Malpighi HospitalBologna Italy
| | - Elisa Boschetti
- Department of Surgical and Medical SciencesUniversity of BolognaBologna Italy
| | | | | | - Carlo Casali
- Department of Medico‐Surgical Sciences and BiotechnologiesUniversity ‘La Sapienza’Rome Italy
| | - Giovanna Cenacchi
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBologna Italy
| | - Manuela Contin
- IRCCS Institute of Neurological Sciences of BolognaBologna Italy
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBologna Italy
| | - Roberto D'Angelo
- Department of Surgical and Medical SciencesUniversity of BolognaBologna Italy
- Neurology UnitSt. Orsola‐Malpighi HospitalBologna Italy
| | | | | | - Raffaele Lodi
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBologna Italy
| | | | - Susan Mohamed
- IRCCS Institute of Neurological Sciences of BolognaBologna Italy
| | | | - Valentina Papa
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBologna Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBologna Italy
| | - Vitaliano Tugnoli
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBologna Italy
| | - Valerio Carelli
- IRCCS Institute of Neurological Sciences of BolognaBologna Italy
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBologna Italy
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35
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Saneto RP. Alpers-Huttenlocher syndrome: the role of a multidisciplinary health care team. J Multidiscip Healthc 2016; 9:323-33. [PMID: 27555780 PMCID: PMC4968991 DOI: 10.2147/jmdh.s84900] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Alpers–Huttenlocher syndrome (AHS) is a mitochondrial DNA-depletion syndrome. Age of onset is bimodal: early onset at 2–4 years and later adolescent onset at 17–24 years of age. Early development is usually normal, with epilepsy heralding the disorder in ~50% of patients. The onset of seizures is coupled with progressive cognitive decline. Hepatopathy is variable, and when present is a progressive dysfunction leading to liver failure in many cases. These features of seizures, cognitive degeneration, and hepatopathy represent the “classic triad” of AHS. However, most patients develop other system involvement. Therefore, although AHS is ultimately a lethal disorder, medical care is required for sustained quality of life. Frequently, additional organ systems – gastrointestinal, respiratory, nutritional, and psychiatric – abnormalities appear and need treatment. Rarely, cardiovascular dysfunction and even pregnancy complicate medical treatment. Optimal care requires a team of physicians and caretakers to make sure quality of life is optimized. The care team, together with the family and palliative care specialists, need to be in communication as the disease progresses and medical changes occur. Although the unpredictable losses of function challenge medical care, the team approach can foster the individual quality-of-life care needed for the patient and family.
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Affiliation(s)
- Russell P Saneto
- Department of Neurology, University of Washington; Division of Pediatric Neurology, Seattle Children's Hospital, Seattle, WA, USA
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36
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A Novel Mutation in Nucleoporin 35 Causes Murine Degenerative Colonic Smooth Muscle Myopathy. THE AMERICAN JOURNAL OF PATHOLOGY 2016; 186:2254-61. [PMID: 27427419 DOI: 10.1016/j.ajpath.2016.04.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/01/2016] [Accepted: 04/26/2016] [Indexed: 11/21/2022]
Abstract
Chronic intestinal pseudo-obstruction (CIPO) is a rare but life-threatening disease characterized by severe intestinal dysmotility. Histopathologic studies in CIPO patients have identified several different mechanisms that appear to be involved in the dysmotility, including defects in neurons, smooth muscle, or interstitial cells of Cajal. Currently there are few mouse models of the various forms of CIPO. We generated a mouse with a point mutation in the RNA recognition motif of the Nup35 gene, which encodes a component of the nuclear pore complex. Nup35 mutants developed a severe megacolon and exhibited a reduced lifespan. Histopathologic examination revealed a degenerative myopathy that developed after birth and specifically affected smooth muscle in the colon; smooth muscle in the small bowel and the bladder were not affected. Furthermore, no defects were found in enteric neurons or interstitial cells of Cajal. Nup35 mice are likely to be a valuable model for the subtype of CIPO characterized by degenerative myopathy. Our study also raises the possibility that Nup35 polymorphisms could contribute to some cases of CIPO.
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37
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Finsterer J, Zarrouk-Mahjoub S. Mitochondrial vasculopathy. World J Cardiol 2016; 8:333-339. [PMID: 27231520 PMCID: PMC4877362 DOI: 10.4330/wjc.v8.i5.333] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 01/16/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023] Open
Abstract
Mitochondrial disorders (MIDs) are usually multisystem disorders (mitochondrial multiorgan disorder syndrome) either on from onset or starting at a point during the disease course. Most frequently affected tissues are those with a high oxygen demand such as the central nervous system, the muscle, endocrine glands, or the myocardium. Recently, it has been shown that rarely also the arteries may be affected (mitochondrial arteriopathy). This review focuses on the type, diagnosis, and treatment of mitochondrial vasculopathy in MID patients. A literature search using appropriate search terms was carried out. Mitochondrial vasculopathy manifests as either microangiopathy or macroangiopathy. Clinical manifestations of mitochondrial microangiopathy include leukoencephalopathy, migraine-like headache, stroke-like episodes, or peripheral retinopathy. Mitochondrial macroangiopathy manifests as atherosclerosis, ectasia of arteries, aneurysm formation, dissection, or spontaneous rupture of arteries. The diagnosis relies on the documentation and confirmation of the mitochondrial metabolic defect or the genetic cause after exclusion of non-MID causes. Treatment is not at variance compared to treatment of vasculopathy due to non-MID causes. Mitochondrial vasculopathy exists and manifests as micro- or macroangiopathy. Diagnosing mitochondrial vasculopathy is crucial since appropriate treatment may prevent from severe complications.
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38
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De Giorgio R, Bianco F, Latorre R, Caio G, Clavenzani P, Bonora E. Enteric neuropathies: Yesterday, Today and Tomorrow. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 891:123-33. [PMID: 27379640 DOI: 10.1007/978-3-319-27592-5_12] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enteric neuropathy is a term indicating an impairment of the innervation supplying the gastrointestinal tract. The clinical phenotypes of the enteric neuropathies are the 'tip of the iceberg' of severe functional digestive diseases, such as intestinal pseudo-obstruction syndromes (e.g., chronic intestinal pseudo-obstruction). Despite progress acquired over the years, the pathogenetic mechanisms leading to enteric neuropathies are still far from being elucidated and the therapeutic approaches to these patients are mainly supportive, rather than curative.The purpose of this chapter is to review the advancements that have been done in the knowledge of enteric neuropathies identified in adult patients ('tomorrow'), going through where we currently are ('today') following a brief history of the major milestones on the pioneering discoveries in the field ('yesterday').
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Affiliation(s)
- Roberto De Giorgio
- Department of Medical and Surgical Sciences, University of Bologna, St. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna, Italy.
- Centro di Ricerca Biomedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy.
| | - Francesca Bianco
- Department of Medical and Surgical Sciences, University of Bologna, St. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna, Italy
- Department of Medical and Veterinary Sciences, University of Bologna, Bologna, Italy
| | - Rocco Latorre
- Department of Medical and Surgical Sciences, University of Bologna, St. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna, Italy
- Centro di Ricerca Biomedica Applicata (C.R.B.A.), University of Bologna, Bologna, Italy
| | - Giacomo Caio
- Department of Medical and Surgical Sciences, University of Bologna, St. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna, Italy
| | - Paolo Clavenzani
- Department of Medical and Veterinary Sciences, University of Bologna, Bologna, Italy
| | - Elena Bonora
- Department of Medical and Surgical Sciences, University of Bologna, St. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna, Italy
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Cabrera-Pérez R, Torres-Torronteras J, Vila-Julià F, Ortega FJ, Cámara Y, Barquinero J, Martí R. Prospective therapeutic approaches in mitochondrial neurogastrointestinal encephalomyopathy (MNGIE). Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1090307] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Fasullo M, Endres L. Nucleotide salvage deficiencies, DNA damage and neurodegeneration. Int J Mol Sci 2015; 16:9431-49. [PMID: 25923076 PMCID: PMC4463597 DOI: 10.3390/ijms16059431] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/16/2015] [Accepted: 04/03/2015] [Indexed: 12/20/2022] Open
Abstract
Nucleotide balance is critically important not only in replicating cells but also in quiescent cells. This is especially true in the nervous system, where there is a high demand for adenosine triphosphate (ATP) produced from mitochondria. Mitochondria are particularly prone to oxidative stress-associated DNA damage because nucleotide imbalance can lead to mitochondrial depletion due to low replication fidelity. Failure to maintain nucleotide balance due to genetic defects can result in infantile death; however there is great variability in clinical presentation for particular diseases. This review compares genetic diseases that result from defects in specific nucleotide salvage enzymes and a signaling kinase that activates nucleotide salvage after DNA damage exposure. These diseases include Lesch-Nyhan syndrome, mitochondrial depletion syndromes, and ataxia telangiectasia. Although treatment options are available to palliate symptoms of these diseases, there is no cure. The conclusions drawn from this review include the critical role of guanine nucleotides in preventing neurodegeneration, the limitations of animals as disease models, and the need to further understand nucleotide imbalances in treatment regimens. Such knowledge will hopefully guide future studies into clinical therapies for genetic diseases.
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Affiliation(s)
- Michael Fasullo
- Colleges of Nanoscale Sciences and Engineering, State University of New York Polytechnic University, Albany, NY 12203, USA.
| | - Lauren Endres
- Colleges of Nanoscale Sciences and Engineering, State University of New York Polytechnic University, Albany, NY 12203, USA.
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Association of Romo1 Gene Genetic Polymorphisms with Risk of Gastric Cancer in Northwestern Chinese Population. Pathol Oncol Res 2014; 21:581-7. [DOI: 10.1007/s12253-014-9858-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
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Dreznik Y, Gutman M, Weiss B, Nevler A. Mitochondrial neuro-gastrointestinal encephalomyopathy presenting with recurrent bowel perforations and intra-abdominal abscesses. J Gastrointest Surg 2014; 18:2054-6. [PMID: 25022257 DOI: 10.1007/s11605-014-2589-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 07/01/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Mitochondrial neuro-gastrointestinal encephalomyopathy syndrome (MNGIE syndrome) is a rare genetic disorder that is defined clinically by severe gastrointestinal dysmotility, cachexia, peripheral neuropathy, ptosis and/or ophthalmoparesis, and leukoencephalopathy. CASE REPORT We report a case of a 26-year-old man with MNGIE syndrome with a unique clinical picture consisting of recurrent episodes of spontaneous bowel perforation and multiple intra-abdominal abscesses. The patient was admitted to our hospital several times in the past few years and underwent urgent laparotomies due to perforations in the small bowel. CONCLUSION Case reports regarding bowel perforations in MNGIE syndrome are scarce and mostly relate to a single perforation and attributed to chronic pseudo-obstruction of the small bowel. To the best of our knowledge, there are no case reports regarding recurrent perforations and abscesses. Surgical management of these cases is challenging as there is no curative option for this genetic disorder. Primary care physicians and treating gastroenterologists should be aware of the potential surgical emergencies associated with this disorder.
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Affiliation(s)
- Yael Dreznik
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel,
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Boschetti E, D’Alessandro R, Bianco F, Carelli V, Cenacchi G, Pinna AD, Gaudio MD, Rinaldi R, Stanghellini V, Pironi L, Rhoden K, Tugnoli V, Casali C, De Giorgio R. Liver as a source for thymidine phosphorylase replacement in mitochondrial neurogastrointestinal encephalomyopathy. PLoS One 2014; 9:e96692. [PMID: 24802030 PMCID: PMC4011889 DOI: 10.1371/journal.pone.0096692] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 04/10/2014] [Indexed: 01/22/2023] Open
Abstract
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a rare autosomal recessive mitochondrial disease associated with mutations in the nuclear TYMP gene. As a result, the thymidine phosphorylase (TP) enzyme activity is markedly reduced leading to toxic accumulation of thymidine and therefore altered mitochondrial DNA. MNGIE is characterized by severe gastrointestinal dysmotility, neurological impairment, reduced life expectancy and poor quality of life. There are limited therapeutic options for MNGIE. In the attempt to restore TP activity, allogenic hematopoietic stem cell transplantation has been used as cellular source of TP. The results of this approach on ∼20 MNGIE patients showed gastrointestinal and neurological improvement, although the 5-year mortality rate is about 70%. In this study we tested whether the liver may serve as an alternative source of TP. We investigated 11 patients (7M; 35–55 years) who underwent hepatic resection for focal disorders. Margins of normal liver tissue were processed to identify, quantify and localize the TP protein by Western Blot, ELISA, and immunohistochemistry, and to evaluate TYMP mRNA expression by qPCR. Western Blot identified TP in liver with a TP/GAPDH ratio of 0.9±0.5. ELISA estimated TP content as 0.5±0.07 ng/μg of total protein. TP was identified in both nuclei and cytoplasm of hepatocytes and sinusoidal lining cells. Finally, TYMP mRNA was expressed in the liver. Overall, our study demonstrates that the liver is an important source of TP. Orthotopic liver transplantation may be considered as a therapeutic alternative for MNGIE patients.
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Affiliation(s)
- Elisa Boschetti
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | | | - Francesca Bianco
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Valerio Carelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giovanna Cenacchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Antonio D. Pinna
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Massimo Del Gaudio
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Rita Rinaldi
- Neurology Unit, St. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Loris Pironi
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Kerry Rhoden
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Vitaliano Tugnoli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Carlo Casali
- Department of Medico-Surgical Sciences and Biotechnologies, University ‘La Sapienza’, Rome, Italy
| | - Roberto De Giorgio
- Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
- * E-mail:
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Garcia-Diaz B, Garone C, Barca E, Mojahed H, Gutierrez P, Pizzorno G, Tanji K, Arias-Mendoza F, Quinzii CM, Hirano M. Deoxynucleoside stress exacerbates the phenotype of a mouse model of mitochondrial neurogastrointestinal encephalopathy. ACTA ACUST UNITED AC 2014; 137:1337-49. [PMID: 24727567 PMCID: PMC3999724 DOI: 10.1093/brain/awu068] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Balanced pools of deoxyribonucleoside triphosphate precursors are required for DNA replication, and alterations of this balance are relevant to human mitochondrial diseases including mitochondrial neurogastrointestinal encephalopathy. In this disease, autosomal recessive TYMP mutations cause severe reductions of thymidine phosphorylase activity; marked elevations of the pyrimidine nucleosides thymidine and deoxyuridine in plasma and tissues, and somatic multiple deletions, depletion and site-specific point mutations of mitochondrial DNA. Thymidine phosphorylase and uridine phosphorylase double knockout mice recapitulated several features of these patients including thymidine phosphorylase activity deficiency, elevated thymidine and deoxyuridine in tissues, mitochondrial DNA depletion, respiratory chain defects and white matter changes. However, in contrast to patients with this disease, mutant mice showed mitochondrial alterations only in the brain. To test the hypothesis that elevated levels of nucleotides cause unbalanced deoxyribonucleoside triphosphate pools and, in turn, pathogenic mitochondrial DNA instability, we have stressed double knockout mice with exogenous thymidine and deoxyuridine, and assessed clinical, neuroradiological, histological, molecular, and biochemical consequences. Mutant mice treated with exogenous thymidine and deoxyuridine showed reduced survival, body weight, and muscle strength, relative to untreated animals. Moreover, in treated mutants, leukoencephalopathy, a hallmark of the disease, was enhanced and the small intestine showed a reduction of smooth muscle cells and increased fibrosis. Levels of mitochondrial DNA were depleted not only in the brain but also in the small intestine, and deoxyribonucleoside triphosphate imbalance was observed in the brain. The relative proportion, rather than the absolute amount of deoxyribonucleoside triphosphate, was critical for mitochondrial DNA maintenance. Thus, our results demonstrate that stress of exogenous pyrimidine nucleosides enhances the mitochondrial phenotype of our knockout mice. Our mouse studies provide insights into the pathogenic role of thymidine and deoxyuridine imbalance in mitochondrial neurogastrointestinal encephalopathy and an excellent model to study new therapeutic approaches.
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Affiliation(s)
- Beatriz Garcia-Diaz
- 1 Department of Neurology, Columbia University Medical Centre, New York, NY, 10032, USA
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Chapman TP, Hadley G, Fratter C, Cullen SN, Bax BE, Bain MD, Sapsford RA, Poulton J, Travis SP. Unexplained gastrointestinal symptoms: think mitochondrial disease. Dig Liver Dis 2014; 46:1-8. [PMID: 23768727 DOI: 10.1016/j.dld.2013.04.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Revised: 04/06/2013] [Accepted: 04/14/2013] [Indexed: 02/08/2023]
Abstract
Defects in mitochondrial function are increasingly recognised as central to the pathogenesis of many diseases, both inherited and acquired. Many of these mitochondrial defects arise from abnormalities in mitochondrial DNA and can result in multisystem disease, with gastrointestinal involvement common. Moreover, mitochondrial disease may present with a range of non-specific symptoms, and thus can be easily misdiagnosed, or even considered to be non-organic. We describe the clinical, histopathological and genetic findings of six patients from three families with gastrointestinal manifestations of mitochondrial disease. In two of the patients, anorexia nervosa was considered as an initial diagnosis. These cases illustrate the challenges of both diagnosing and managing mitochondrial disease and highlight two important but poorly understood aspects, the clinical and the genetic. The pathophysiology of gastrointestinal involvement in mitochondrial disease is discussed and emerging treatments are described. Finally, we provide a checklist of investigations for the gastroenterologist when mitochondrial disease is suspected.
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Affiliation(s)
- Thomas P Chapman
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Gina Hadley
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Carl Fratter
- Oxford Medical Genetics Laboratories, Churchill Hospital, Oxford, UK
| | - Sue N Cullen
- Buckinghamshire Hospitals NHS Trust, Department of Gastroenterology, Level 6, Queen Alexandra Road, High Wycombe, UK
| | - Bridget E Bax
- Division of Clinical Sciences, St. George's University of London, London, UK
| | - Murray D Bain
- Division of Clinical Sciences, St. George's University of London, London, UK
| | | | - Joanna Poulton
- Nuffield Dept Obstetrics and Gynaecology, University of Oxford, The Women's Centre, Oxford, UK
| | - Simon P Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.
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Augustin J, Hoyeau N, Sokol H, Fléjou JF, Svrcek M. [A colourful villous atrophy]. Ann Pathol 2013; 33:418-20. [PMID: 24331726 DOI: 10.1016/j.annpat.2013.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 10/22/2013] [Accepted: 10/23/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Jérémy Augustin
- Service d'anatomie et cytologie pathologiques, hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Nadia Hoyeau
- Service d'anatomie et cytologie pathologiques, hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Harry Sokol
- Service de gastroentérologie et nutrition, hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Jean-François Fléjou
- Service d'anatomie et cytologie pathologiques, hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Magali Svrcek
- Service d'anatomie et cytologie pathologiques, hôpital Saint-Antoine, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
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Abstract
To highlight differences between early-onset and adult mitochondrial depletion syndromes (MDS) concerning etiology and genetic background, pathogenesis, phenotype, clinical presentation and their outcome. MDSs most frequently occur in neonates, infants, or juveniles and more rarely in adolescents or adults. Mutated genes phenotypically presenting with adult-onset MDS include POLG1, TK2, TyMP, RRM2B, or PEO1/twinkle. Adult MDS manifest similarly to early-onset MDS, as myopathy, encephalo-myopathy, hepato-cerebral syndrome, or with chronic progressive external ophthalmoplegia (CPEO), fatigue, or only minimal muscular manifestations. Diagnostic work-up or treatment is not at variance from early-onset cases. Histological examination of muscle may be normal but biochemical investigations may reveal multiple respiratory chain defects. The outcome appears to be more favorable in adult than in early-onset forms. Mitochondrial depletion syndromes is not only a condition of neonates, infants, or juveniles but rarely also occurs in adults, presenting with minimal manifestations or manifestations like in the early-onset forms. Outcome of adult-onset MDS appears more favorable than early-onset MDS.
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Paine P, McLaughlin J, Lal S. Review article: the assessment and management of chronic severe gastrointestinal dysmotility in adults. Aliment Pharmacol Ther 2013; 38:1209-29. [PMID: 24102305 DOI: 10.1111/apt.12496] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 02/27/2013] [Accepted: 08/30/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The characterisation and management of chronic severe gastrointestinal (GI) dysmotility are challenging. It may cause intestinal failure requiring home parenteral nutrition (HPN). AIMS To review the presentation, aetiology, characterisation, management and outcome of chronic severe GI dysmotility, and to suggest a pragmatic management algorithm. METHODS PubMed search was performed up to December 2012 using appropriate search terms, restricted to human articles and reviewed for relevance. Segmental dysmotility, acute ileus, functional syndromes and non-English articles were excluded. Evidence and recommendations were evaluated using the GRADE system. RESULTS In total, 721 relevant articles were reviewed. A coherent and definitive picture is hampered by overlapping classification systems using multi-modal characterisation methods, subject to pitfalls and some requiring further validation. The literature is confined to case series with no randomised trials. Fewer than 20% undergo full thickness jejunal biopsy, which are otherwise labelled idiopathic. However, in studies with up to 80% biopsy rates, neuromuscular abnormalities may be found in 90%. Between 14% and 50% will require HPN, comprising 8-14% of all HPN patients, of which 2/3 are primary/idiopathic and 1/3 secondary, with scleroderma being the leading secondary cause. Ten-year mortality ranges from 13% to 35% and is worst in elderly scleroderma patients. Management includes limited treatments for secondary causes, prokinetics, symptom palliation, psychological support, nutrition, hydration and judicious surgery. CONCLUSIONS Severe dysmotility often remains idiopathic. It is rarely possible to alter disease trajectory; consequently, prognosis may be poor. Multi-disciplinary teams in a specialist setting can improve outcomes. Graded recommendations are enumerated and a pragmatic algorithm is suggested.
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Affiliation(s)
- P Paine
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK; Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Finsterer J, G Kovacs G, Ahting U. Adult mitochondrial DNA depletion syndrome with mild manifestations. Neurol Int 2013; 5:28-30. [PMID: 23888212 PMCID: PMC3718249 DOI: 10.4081/ni.2013.e9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/06/2013] [Indexed: 12/13/2022] Open
Abstract
Mitochondrial DNA depletion syndrome (MDS) is usually a severe disorder of infancy or childhood, due to a reduced copy number of mtDNA molecules. MDS with only mild, nonspecific clinical manifestations and onset in adulthood has not been reported. A 47-year-old Caucasian female with short stature and a history of migraine, endometriosis, Crohn's disease, C-cell carcinoma of the thyroid gland, and a family history positive for mitochondrial disorder (2 sisters, aunt, niece), developed day-time sleepiness, exercise intolerance, and myalgias in the lower-limb muscles since age 46y. She slept 9-10 hours during the night and 2 hours after lunch daily. Clinical exam revealed sore neck muscles, bilateral ptosis, and reduced Achilles tendon reflexes exclusively. Blood tests revealed hyperlipidemia exclusively. Nerve conduction studies, needle electromyography, and cerebral and spinal magnetic resonance imaging were noninformative. Muscle biopsy revealed detached lobulated fibers with subsarcolemmal accentuation of the NADH and SDH staining. Realtime polymerase chain reaction revealed depletion of the mtDNA down to 9% of normal. MDS may be associated with a mild phenotype in adults and may not significantly progress during the first year after onset. In an adult with hypersomnia, severe tiredness, exercise intolerance, and a family history positive for mitochondrial disorder, a MDS should be considered.
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Imai DM, Miller JL, Leonard BC, Bach J, Drees R, Steinberg H, Teixeira LBC. Visceral smooth muscle α-actin deficiency associated with chronic intestinal pseudo-obstruction in a Bengal cat (Felis catus x Prionailurus bengalensis). Vet Pathol 2013; 51:612-8. [PMID: 23774747 DOI: 10.1177/0300985813492802] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An adult Bengal cat (Felis catus × Prionailurus bengalensis) with a prolonged history of partial anorexia, regurgitation, and weight loss and a clinical, radiographic, and ultrasonographic diagnosis of persistent megaesophagus and gastrointestinal ileus was submitted for necropsy. The intestinal tract was diffusely distended by gas and fluid with appreciable loss of muscle tone and an absence of luminal obstruction, consistent with the clinical history of chronic intestinal pseudo-obstruction. Histologically, the autonomic nervous system was intact, but the smooth muscle within the gastrointestinal wall exhibited a marked basophilia that was most pronounced in the jejunum. Immunohistochemistry for neurofilament, synaptophysin, CD117, and desmin demonstrated that the number of myenteric ganglia, number of interstitial cells, and leiomyocyte desmin content were similar when compared with the unaffected age- and species-matched control. Immunohistochemistry for smooth muscle α-actin demonstrated a striking loss of immunoreactivity, predominantly in the circular layer of the jejunum, that corresponded with the tinctorial change in leiomyocytes. Transmission electron microscopy revealed loss of myofibrils, loss of organelle polarity, and significantly larger central mitochondria (megamitochondria) in affected leiomyocytes, as well as nonspecific degenerative changes. Although the presence of a primary leiomyopathy and a causal relationship could not be confirmed in this case, leiomyopathies are considered a cause of chronic intestinal pseudo-obstruction in human medicine, and loss of smooth muscle α-actin immunoreactivity is one recognized marker for intestinal dysmotility.
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Affiliation(s)
- D M Imai
- Department of Pathobiological Sciences, School of Veterinary Medicine, University of Wisconsin, 2015 Linden Dr West, Madison, WI 53706, USA.
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