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Barros CDS, Coutinho A, Tengan CH. Arginine Supplementation in MELAS Syndrome: What Do We Know about the Mechanisms? Int J Mol Sci 2024; 25:3629. [PMID: 38612442 PMCID: PMC11011289 DOI: 10.3390/ijms25073629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
MELAS syndrome, characterized by mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes, represents a devastating mitochondrial disease, with the stroke-like episodes being its primary manifestation. Arginine supplementation has been used and recommended as a treatment for these acute attacks; however, insufficient evidence exists to support this treatment for MELAS. The mechanisms underlying the effect of arginine on MELAS pathophysiology remain unclear, although it is hypothesized that arginine could increase nitric oxide availability and, consequently, enhance blood supply to the brain. A more comprehensive understanding of these mechanisms is necessary to improve treatment strategies, such as dose and regimen adjustments; identify which patients could benefit the most; and establish potential markers for follow-up. This review aims to analyze the existing evidence concerning the mechanisms through which arginine supplementation impacts MELAS pathophysiology and provide the current scenario and perspectives for future investigations.
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Affiliation(s)
| | | | - Celia H. Tengan
- Division of Neurology, Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04039-032, Brazil; (C.D.S.B.); (A.C.)
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Guerrero-Molina MP, Bernabeu-Sanz Á, Ramos-González A, Morales-Conejo M, Delmiro A, Domínguez-González C, Arenas J, Martín MA, González de la Aleja J. Magnetic resonance spectroscopy in MELAS syndrome: correlation with CSF and plasma metabolite levels and change after glutamine supplementation. Neuroradiology 2024; 66:389-398. [PMID: 38114794 DOI: 10.1007/s00234-023-03263-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/02/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE MELAS syndrome is a genetic disorder caused by mitochondrial DNA mutations. We previously described that MELAS patients had increased CSF glutamate and decreased CSF glutamine levels and that oral glutamine supplementation restores these values. Proton magnetic resonance spectroscopy (1H-MRS) allows the in vivo evaluation of brain metabolism. We aimed to compare 1H-MRS of MELAS patients with controls, the 1H-MRS after glutamine supplementation in the MELAS group, and investigate the association between 1H-MRS and CSF lactate, glutamate, and glutamine levels. METHODS We conducted an observational case-control study and an open-label, single-cohort study with single-voxel MRS (TE 144/35 ms). We assessed the brain metabolism changes in the prefrontal (PFC) and parieto-occipital) cortex (POC) after oral glutamine supplementation in MELAS patients. MR spectra were analyzed with jMRUI software. RESULTS Nine patients with MELAS syndrome (35.8 ± 3.2 years) and nine sex- and age-matched controls were recruited. Lactate/creatine levels were increased in MELAS patients in both PFC and POC (0.40 ± 0.05 vs. 0, p < 0.001; 0.32 ± 0.03 vs. 0, p < 0.001, respectively). No differences were observed between groups in glutamate and glutamine (Glx/creatine), either in PFC (p = 0.930) or POC (p = 0.310). No differences were observed after glutamine supplementation. A positive correlation was found between CSF lactate and lactate/creatine only in POC (0.85, p = 0.003). CONCLUSION No significant metabolite changes were observed in the brains of MELAS patients after glutamine supplementation. While we found a positive correlation between lactate levels in CSF and 1H-MRS in MELAS patients, we could not monitor treatment response over short periods with this tool. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04948138; initial release 24/06/2021; first patient enrolled on 1/07/2021. https://clinicaltrials.gov/ct2/show/NCT04948138.
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Affiliation(s)
- María Paz Guerrero-Molina
- Neurology Department, Neuromuscular Disorders Unit, University Hospital, 12 de Octubre Avda. de Córdoba, S/N 28041, Madrid, Spain.
| | | | - Ana Ramos-González
- Department of Neuroradiology, University Hospital, 12 de Octubre, Madrid, Spain
| | - Montserrat Morales-Conejo
- Department of Internal Medicine, University Hospital, 12 de Octubre, Madrid, Spain
- National Reference Center for Congenital Errors of Metabolism (CSUR) an European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, 12 de Octubre, Madrid, Spain
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), U723, Madrid, Spain
| | - Aitor Delmiro
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), U723, Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital, 12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, 12 de Octubre, Madrid, Spain
| | - Cristina Domínguez-González
- Neurology Department, Neuromuscular Disorders Unit, University Hospital, 12 de Octubre Avda. de Córdoba, S/N 28041, Madrid, Spain
- National Reference Center for Congenital Errors of Metabolism (CSUR) an European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, 12 de Octubre, Madrid, Spain
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), U723, Madrid, Spain
- Research Institute ('imas12'), University Hospital, 12 de Octubre, Madrid, Spain
| | - Joaquín Arenas
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), U723, Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital, 12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, 12 de Octubre, Madrid, Spain
| | - Miguel A Martín
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), U723, Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital, 12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, 12 de Octubre, Madrid, Spain
| | - Jesús González de la Aleja
- National Reference Center for Congenital Errors of Metabolism (CSUR) an European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, 12 de Octubre, Madrid, Spain
- Neurology Department, Epilepsy Unit, University Hospital, 12 de Octubre, Madrid, Spain
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Bornstein R, Mulholland MT, Sedensky M, Morgan P, Johnson SC. Glutamine metabolism in diseases associated with mitochondrial dysfunction. Mol Cell Neurosci 2023; 126:103887. [PMID: 37586651 PMCID: PMC10773532 DOI: 10.1016/j.mcn.2023.103887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/10/2023] [Accepted: 08/13/2023] [Indexed: 08/18/2023] Open
Abstract
Mitochondrial dysfunction can arise from genetic defects or environmental exposures and impact a wide range of biological processes. Among these are metabolic pathways involved in glutamine catabolism, anabolism, and glutamine-glutamate cycling. In recent years, altered glutamine metabolism has been found to play important roles in the pathologic consequences of mitochondrial dysfunction. Glutamine is a pleiotropic molecule, not only providing an alternate carbon source to glucose in certain conditions, but also playing unique roles in cellular communication in neurons and astrocytes. Glutamine consumption and catabolic flux can be significantly altered in settings of genetic mitochondrial defects or exposure to mitochondrial toxins, and alterations to glutamine metabolism appears to play a particularly significant role in neurodegenerative diseases. These include primary mitochondrial diseases like Leigh syndrome (subacute necrotizing encephalopathy) and MELAS (mitochondrial myopathy with encephalopathy, lactic acidosis, and stroke-like episodes), as well as complex age-related neurodegenerative disorders such as Alzheimer's and Parkinson's diseases. Pharmacologic interventions targeting glutamine metabolizing and catabolizing pathways appear to provide some benefits in cell and animal models of these diseases, indicating glutamine metabolism may be a clinically relevant target. In this review, we discuss glutamine metabolism, mitochondrial disease, the impact of mitochondrial dysfunction on glutamine metabolic processes, glutamine in neurodegeneration, and candidate targets for therapeutic intervention.
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Affiliation(s)
- Rebecca Bornstein
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, USA
| | - Michael T Mulholland
- Department of Applied Sciences, Translational Bioscience, Northumbria University, Newcastle, UK
| | - Margaret Sedensky
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| | - Phil Morgan
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| | - Simon C Johnson
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, USA; Department of Neurology, University of Washington, Seattle, USA; Department of Applied Sciences, Translational Bioscience, Northumbria University, Newcastle, UK.
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Guerrero-Molina MP, Morales-Conejo M, Delmiro A, Morán M, Domínguez-González C, Arranz-Canales E, Ramos-González A, Arenas J, Martín MA, de la Aleja JG. High-dose oral glutamine supplementation reduces elevated glutamate levels in cerebrospinal fluid in patients with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes syndrome. Eur J Neurol 2023; 30:538-547. [PMID: 36334048 DOI: 10.1111/ene.15626] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/07/2022] [Accepted: 10/27/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) syndrome is a genetically heterogeneous disorder caused by mitochondrial DNA mutations. There are no disease-modifying therapies, and treatment remains mainly supportive. It has been shown previously that patients with MELAS syndrome have significantly increased cerebrospinal fluid (CSF) glutamate and significantly decreased CSF glutamine levels compared to controls. Glutamine has many metabolic fates in neurons and astrocytes, and the glutamate-glutamine cycle couples with many metabolic pathways depending on cellular requirements. The aim was to compare CSF glutamate and glutamine levels before and after dietary glutamine supplementation. It is postulated that high-dose oral glutamine supplementation could reduce the increase in glutamate levels. METHOD This open-label, single-cohort study determined the safety and changes in glutamate and glutamine levels in CSF after 12 weeks of oral glutamine supplementation. RESULTS Nine adult patients with MELAS syndrome (66.7% females, mean age 35.8 ± 3.2 years) were included. After glutamine supplementation, CSF glutamate levels were significantly reduced (9.77 ± 1.21 vs. 18.48 ± 1.34 μmol/l, p < 0.001) and CSF glutamine levels were significantly increased (433.66 ± 15.31 vs. 336.31 ± 12.92 μmol/l, p = 0.002). A side effect observed in four of nine patients was a mild sensation of satiety. One patient developed mild and transient elevation of transaminases, and another patient was admitted for an epileptic status without stroke-like episode. DISCUSSION This study demonstrates that high-dose oral glutamine supplementation significantly reduces CSF glutamate and increases CSF glutamine levels in patients with MELAS syndrome. These findings may have potential therapeutic implications in these patients. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT04948138. Initial release 24 June 2021, first patient enrolled 1 July 2021. https://clinicaltrials.gov/ct2/show/NCT04948138.
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Affiliation(s)
| | - Montserrat Morales-Conejo
- Department of Internal Medicine, University Hospital, Madrid, Spain
- National Reference Center for Congenital Errors of Metabolism (CSUR) and European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, Madrid, Spain
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
| | - Aitor Delmiro
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - María Morán
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Cristina Domínguez-González
- Neurology Department, Neuromuscular Disorders Unit, University Hospital, Madrid, Spain
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Elena Arranz-Canales
- Department of Internal Medicine, University Hospital, Madrid, Spain
- National Reference Center for Congenital Errors of Metabolism (CSUR) and European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, Madrid, Spain
| | | | - Joaquín Arenas
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Miguel A Martín
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Jesús González de la Aleja
- National Reference Center for Congenital Errors of Metabolism (CSUR) and European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, Madrid, Spain
- Neurology Department, Epilepsy Unit, University Hospital, Madrid, Spain
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Tang Q, Ye XM, Yang YC, Wen XL. Growth hormone therapy for mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes: A case report. Asian J Surg 2023; 46:663-664. [PMID: 35864039 DOI: 10.1016/j.asjsur.2022.07.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/08/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Qiong Tang
- Department of Children Health Care Center, Zhuzhou Hospital Affiliated to Xiangya Medical College, Central South University, Zhuzhou Ctity, Hunan Province, 412007, China
| | - Xiao-Min Ye
- Department of Children Health Care Center, Zhuzhou Hospital Affiliated to Xiangya Medical College, Central South University, Zhuzhou Ctity, Hunan Province, 412007, China
| | - Yi-Can Yang
- Department of Children Health Care Center, Zhuzhou Hospital Affiliated to Xiangya Medical College, Central South University, Zhuzhou Ctity, Hunan Province, 412007, China
| | - Xiang-Lan Wen
- Department of Children Health Care Center, Zhuzhou Hospital Affiliated to Xiangya Medical College, Central South University, Zhuzhou Ctity, Hunan Province, 412007, China.
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Ni Cathain D, Browne E, Skehan K, Boyle K. MELAS syndrome: an acute stroke-like episode complicated by renal tubular acidosis. BMJ Case Rep 2021; 14:e245898. [PMID: 34728512 PMCID: PMC8565551 DOI: 10.1136/bcr-2021-245898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/03/2022] Open
Abstract
MELAS, a mitochondrially inherited multisystem disorder, can present with acute stroke-like episodes. The literature thus far supports the use of L-arginine therapy in acute MELAS flares to alleviate and shorten the duration of symptoms. This is the case of a patient who presented with ataxia and worsening confusion on a background of genetically confirmed MELAS syndrome. In this instance, intravenous L-arginine therapy, along with corticosteroids, was administered in keeping with best practice. However, in a metabolically vulnerable patient, L-arginine therapy resulted in a further deterioration in his clinical status and the development of a non-anion gap metabolic acidosis.
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Rodan LH, Poublanc J, Fisher JA, Sobczyk O, Mikulis DJ, Tein I. L-arginine effects on cerebrovascular reactivity, perfusion and neurovascular coupling in MELAS (mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes) syndrome. PLoS One 2020; 15:e0238224. [PMID: 32881886 PMCID: PMC7470264 DOI: 10.1371/journal.pone.0238224] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 08/11/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE We previously showed that MELAS patients have decreased cerebrovascular reactivity (CVR) (p≤ 0.002) and increased cerebral blood flow (CBF) (p<0.0026); changes correlated with disease severity and % mutant mtDNA (inversely for CVR; directly for CBF). We ran a prospective pilot in 3 MELAS sibs (m.3243A>G tRNALeu(UUR)) with variable % mutant blood mtDNA to assess effects of L-Arginine (L-Arg) (single dose and 6-wk steady-state trial) on regional CBF, arterial CVR and neurovascular coupling. METHODS Patients were studied with 3T MRI using arterial spin labeling (ASL) to measure CBF and changes in % Blood Oxygen Level Dependent (BOLD) signal to changes in arterial partial pressure of CO2 to measure CVR. Task fMRI consisted of an alternating black and white checkerboard to evaluate visual cortex response in MELAS and controls. RESULTS Following L-Arg, there was restoration of serum Arg (76-230 μM) in MELAS sibs and a trend towards increasing CVR in frontal and corresponding decrease in occipital cortex; CVR was unchanged globally. There was a 29-37% reduction in baseline CBF in one patient following 6 wks of L-Arg. Pre-treatment fMRI activation in response to visual cortex stimulus was markedly decreased in the same patient compared to controls in primary visual striate cortex V1 and extrastriate regions V2 to V5 with a marked increase toward control values following a single dose and 6 wks of L-Arg. CONCLUSION Proposed "healing" effect may be due to more efficient utilization of energy substrates with increased cellular energy balances and ensuing reduction in signalling pathways that augment flow in the untreated state. CLASSIFICATION OF EVIDENCE This prospective pilot study provides Class III evidence that oral L-Arginine (100 mg/kg single dose or 100 mg/kg three times daily po X 6 weeks) normalizes resting blood flow from elevated pre-treatment levels in patients with MELAS syndrome, selectively increases their CVR from reduced pre-treatment levels in regions most impaired at the expense of less abnormal regions, and normalizes reduced BOLD fMRI activation in response to visual cortex stimulus. CLINICAL TRIALS.GOV (NIH) NCT01603446.
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Affiliation(s)
- Lance H. Rodan
- Division of Neurology, Dept. of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Julien Poublanc
- Dept. of Medical Imaging, The Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joseph A. Fisher
- Dept. of Anesthesiology, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Dept. of Physiology and Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- The Toronto General Hospital Medical Research Institute, Toronto, Ontario, Canada
| | - Olivia Sobczyk
- Dept. of Medical Imaging, The Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David J. Mikulis
- Dept. of Medical Imaging, The Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ingrid Tein
- Division of Neurology, Dept. of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Genetics and Genome Biology Program, The Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Dept. of Laboratory Medicine and Pathobiology, The University of Toronto, Toronto, Ontario, Canada
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Wang S, Song T, Wang S. Mitochondrial DNA 10158T>C mutation in a patient with mitochondrial encephalomyopathy with lactic acidosis, and stroke-like episodes syndrome: A case-report and literature review (CARE-complaint). Medicine (Baltimore) 2020; 99:e20310. [PMID: 32541454 PMCID: PMC7302614 DOI: 10.1097/md.0000000000020310] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Mitochondrial encephalomyopathy with lactic acidosis and stroke- like episodes (MELAS) syndrome is caused by mitochondrial respiratory chain dysfunction and oxidative phosphorylation disorder. It is a rare clinical metabolic disease involved with multiple systems. PATIENT CONCERNS A 22-year-old patient presented with limb convulsion accompanied by loss of consciousness, headache, partial blindness, blurred vision, and so on. DIAGNOSES Brain magnetic resonance imaging showed a high-intensity area in bilateral occipital cortex, left parietal lobe and cerebellum on diffusion-weighted imaging. These focus did not distribute as vascular territory. The pathological examination of skeletal muscle revealed several succinate dehydrogenase reactive vessels with overreaction and increased content of lipid droplets in some muscle fibers. Genetic testing showed that the patient carried m.10158T>C mutation. INTERVENTIONS She was provided with traditional arginine hydrochloride therapy and orally medication of coenzyme Q (10 mg). OUTCOMES Mitochondrial DNA of blood and hair follicle of patient carried m.10158T>C mutation LESSONS:: For the suspected patients of MELAS syndrome, if the hot-spot mutation test is negative, more detection sites should be selected.
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Abstract
INTRODUCTION Stroke-like episodes (SLEs) are typical cerebral manifestations of certain mitochondrial disorders (MIDs). They are characterised by a vasogenic edema in a non-vascular distribution. PATIENTS CONCERNS:: none DIAGNOSIS:: SLEs show up on cerebral MRI as stroke-like lesions (SLLs), characterised by vasogenic edema in a non-vascular distribution. SLLs expand in the acute stage and regress during the chronic stage. They show hyperperfusion in the acute stage and hypoperfusion in the chronic stage. INTERVENTIONS SLLs respond favorably to antiseizure drugs, to No-precursors, steroids, the ketogenic diet, and antioxidants. OUTCOME SLLs end up as normal tissue, white matter lesion, grey matter lesion, cyst, laminar cortical necrosis, or the toenail sign. CONCLUSIONS SLLs are a frequent manifestation of MIDs. They undergo dynamic changes in the acute and chronic stage. They need to be differentiated from ischemic stroke as they are differentially treated.
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MESH Headings
- Acidosis, Lactic/diagnosis
- Anticonvulsants/therapeutic use
- Antioxidants/therapeutic use
- Asian People/ethnology
- Brain Diseases, Metabolic, Inborn/complications
- Brain Diseases, Metabolic, Inborn/diagnosis
- Brain Diseases, Metabolic, Inborn/drug therapy
- Brain Edema/diagnostic imaging
- Child
- DNA, Mitochondrial/genetics
- Diagnosis, Differential
- Diet, Ketogenic/adverse effects
- Diet, Ketogenic/methods
- Encephalitis/diagnosis
- Encephalitis/drug therapy
- Humans
- MELAS Syndrome/diagnostic imaging
- MELAS Syndrome/drug therapy
- MELAS Syndrome/genetics
- MELAS Syndrome/pathology
- Magnetic Resonance Imaging
- Male
- Mitochondrial Diseases/complications
- Mitochondrial Encephalomyopathies/diagnosis
- Oxidative Phosphorylation/drug effects
- Stroke/classification
- Stroke/drug therapy
- Stroke/pathology
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Miyauchi A, Kouga T, Jimbo EF, Matsuhashi T, Abe T, Yamagata T, Osaka H. Apomorphine rescues reactive oxygen species-induced apoptosis of fibroblasts with mitochondrial disease. Mitochondrion 2019; 49:111-120. [PMID: 31356884 DOI: 10.1016/j.mito.2019.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 06/26/2019] [Accepted: 07/22/2019] [Indexed: 12/18/2022]
Abstract
Mitochondrial disease is a genetic disorder in which individuals suffer from energy insufficiency. The various clinical phenotypes of mitochondrial disease include Leigh syndrome (LS), myopathy encephalopathy lactic acidosis and stroke-like episodes (MELAS). Thus far, no curative treatment is available, and effective treatment options are eagerly awaited. We examined the cell protective effect of an existing commercially available chemical library on fibroblasts from four patients with LS and MELAS and identified apomorphine as a potential therapeutic drug for mitochondrial disease. We conducted a cell viability assay under oxidative stress induced by L-butionine (S, R)-sulfoximine (BSO), a glutathione synthesis inhibitor. Among the chemicals of library, 4 compounds (apomorphine, olanzapine, phenothiazine and ethopropazine) rescued cells from death induced by oxidative stress much more effectively than idebenone, which was used as a positive control. The EC50 value showed that apomorphine was the most effective compound. Apomorphine also significantly improved all of the assessed oxygen consumption rate values by the extracellular flux analyzer for fibroblasts from LS patients with complex I deficiency. In addition, the elevation of the Growth Differentiation Factor-15 (GDF-15), a biomarker of mitochondrial disease, was significantly reduced by apomorphine. Among 441 apomorphine-responsive genes identified by the microarray, apomorphine induced the expression of genes that inhibit the mammalian target of rapamycin (mTOR) activity and inflammatory responses, suggesting that apomorphine induced cell survival via a new potential pathway. In conclusion, apomorphine rescued fibroblasts from cell death under oxidative stress and improved the mitochondrial respiratory activity and appears to be potentially useful for treating mitochondrial disease.
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Affiliation(s)
- Akihiko Miyauchi
- Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Takeshi Kouga
- Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Eriko F Jimbo
- Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Tetsuro Matsuhashi
- Department of Medical Science, Tohoku University Graduate School of Biomedical Engineering, Sendai, Japan; Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaaki Abe
- Department of Medical Science, Tohoku University Graduate School of Biomedical Engineering, Sendai, Japan; Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; Department of Clinical Biology and Hormonal Regulation, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Hitoshi Osaka
- Department of Pediatrics, Jichi Medical University, Tochigi, Japan.
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Abstract
RATIONALE Mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS) are thought to be rarely accompanied by macroangiopathy. We reported a case of MELAS that presented right distal internal carotid arterial (ICA) stenosis and reviewed 12 similar previously reported cases involving intracranial large blood vessels. PATIENT CONCERNS A 38-year-old man suffered from recurrent stroke-like episodes (SE) such as alternating hemiparesis (right lesion 3 years ago and current left lesion), cortical blindness and seizure for 3 years, and was previously misdiagnosed as cerebral infarction. Magnetic Resonance Angiography (MRA) and Digital Subtraction Angiography (DSA) revealed right distal ICA stenosis and sparse cortex blood vessels, which were related to the previous SE. DIAGNOSES He was diagnosed by genetic screening (a mitochondrial DNA A3243G point mutation) and presence of high lactic acidosis (4.03 mmol/L), which rose to 7.8 mmol/L after exercise. INTERVENTION The patient received Coenzyme Q10, vitamin C, L-arginine for 2 weeks and valproic acid sodium (400 mg bid) to prevent seizures till now. OUTCOMES He is currently less active and intelligent than his peers, with occasional seizures, and needs family care. LESSONS Till date, there are 12 reported cases of MELAS combined with major cerebral arteries abnormalities including stenosis, dissection, occlusion, reversible vasoconstriction, aneurysms, and atherosclerosis. Hence, macroangiopathy in MELAS is not very rare. There is correlation between the affected vessels and the lesions in some cases, but not in others, which may increase the misdiagnosis rate. Hence, mitochondrial diseases cannot be excluded due to concurrent macroangiopathic lesions.
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Choi HS, Lee JH, Lee SH, Lee YM. Avascular necrosis after long-term glucocorticoid treatment in MELAS: a cautionary note. J Inherit Metab Dis 2018; 41:277-278. [PMID: 29110176 DOI: 10.1007/s10545-017-0110-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Han Som Choi
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Jae Hyun Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Sun Ho Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, Republic of Korea
| | - Young-Mock Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, Republic of Korea.
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Modrzejewska M, Chrzanowska M, Modrzejewska A, Romanowska H, Ostrowska I, Giżewska M. [Ocular findings in MELAS syndrome – a case report]. Klin Oczna 2016; 118:301-307. [PMID: 29911364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We present a case of a child with MELAS syndrome (mitochondrial encephalo-myopathy with lactic acidosis and stroke-like episodes), discussing clinical manifestation, ocular findings and diagnostic challenges. Predominant ocular symptom was a transient complete visual loss, while the predominant ocular sign was a visual field defect. The diagnosia was based on clinical manifestation, laboratory tests, brain scans and genetic testing which confirmed the pathognomonic mutation in the MTTL1 gene encoding the mitochondrial tRNA for leucine 3243> G. Ocular examination demonstrated decreased visual acuity (with bilateral best corrected visual acuity of .1). Periodical, transient visual loss and visual field defects were clinically predominant. Specialist investigations were carried out, which demonstrated homonymous hemianopia (kinetic perimetry), bilateral partial optic nerve atrophy (RetCam). Funduscopy and electrophysiology mfERG study did not confirm features of retinitis pigmentosa. The brain scans revealed numerous small cortical ischemic lesions within the frontal, parietal and temporal lobes, post-stroke focal areas within the occipital lobes and diffuse calcifications of the basal ganglia. During several years of follow-up, visual field defects showed progressive concentric narrowing. The patient received a long-term treatment with arginine, coenzyme Q and vitamin D, both oral and intravenous, but no beneficial effect for the improvement of ophthalmic condition was observed. As it is the case in severe MELAS syndrome, the course of disease was fatal and the patientdied at the age of 14.
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Rodan LH, Wells GD, Banks L, Thompson S, Schneiderman JE, Tein I. L-Arginine Affects Aerobic Capacity and Muscle Metabolism in MELAS (Mitochondrial Encephalomyopathy, Lactic Acidosis and Stroke-Like Episodes) Syndrome. PLoS One 2015; 10:e0127066. [PMID: 25993630 PMCID: PMC4439047 DOI: 10.1371/journal.pone.0127066] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 04/10/2015] [Indexed: 11/23/2022] Open
Abstract
Objective To study the effects of L-arginine (L-Arg) on total body aerobic capacity and muscle metabolism as assessed by 31Phosphorus Magnetic Resonance Spectroscopy (31P-MRS) in patients with MELAS (Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like episodes) syndrome. Methods We performed a case control study in 3 MELAS siblings (m.3243A>G tRNAleu(UUR) in MTTL1 gene) with different % blood mutant mtDNA to evaluate total body maximal aerobic capacity (VO2peak) using graded cycle ergometry and muscle metabolism using 31P-MRS. We then ran a clinical trial pilot study in MELAS sibs to assess response of these parameters to single dose and a 6-week steady-state trial of oral L-Arginine. Results At baseline (no L-Arg), MELAS had lower serum Arg (p = 0.001). On 31P-MRS muscle at rest, MELAS subjects had increased phosphocreatine (PCr) (p = 0.05), decreased ATP (p = 0.018), and decreased intracellular Mg2+ (p = 0.0002) when compared to matched controls. With L-arginine therapy, the following trends were noted in MELAS siblings on cycle ergometry: (1) increase in mean % maximum work at anaerobic threshold (AT) (2) increase in % maximum heart rate at AT (3) small increase in VO2peak. On 31P-MRS the following mean trends were noted: (1) A blunted decrease in pH after exercise (less acidosis) (2) increase in Pi/PCr ratio (ADP) suggesting increased work capacity (3) a faster half time of PCr recovery (marker of mitochondrial activity) following 5 minutes of moderate intensity exercise (4) increase in torque. Significance These results suggest an improvement in aerobic capacity and muscle metabolism in MELAS subjects in response to supplementation with L-Arg. Intramyocellular hypomagnesemia is a novel finding that warrants further study. Classification of Evidence Class III evidence that L-arginine improves aerobic capacity and muscle metabolism in MELAS subjects. Trial Registration ClinicalTrials.gov NCT01603446.
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Affiliation(s)
- Lance H. Rodan
- Division of Neurology, Dept. of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada, M5G 1X8
| | - Greg D. Wells
- Physiology and Experimental Medicine Program, Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada, M5G 1X8
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ont., Canada, M5G 1X8
| | - Laura Banks
- Physiology and Experimental Medicine Program, Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada, M5G 1X8
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ont., Canada, M5G 1X8
| | - Sara Thompson
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ont., Canada, M5G 1X8
| | - Jane E. Schneiderman
- Physiology and Experimental Medicine Program, Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada, M5G 1X8
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ont., Canada, M5G 1X8
| | - Ingrid Tein
- Division of Neurology, Dept. of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada, M5G 1X8
- Dept. of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ont., Canada, M5G 1X8
- * E-mail:
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Matsui J, Takano T, Ryujin F, Anzai Y, Yoshioka S, Takeuchi Y, Goto Y. [A case of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episode/Leigh overlap syndrome]. No To Hattatsu 2014; 46:363-366. [PMID: 25403068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
We experienced a case in which mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) was identified as complications following the onset of Leigh syndrome along with a 10191 T>C mutation of the mitochondrial gene. The case pertains to a 26-year-old woman. The disease appeared when she was 11 years old due to divergent strabismus, at which point a diagnosis of juvenile Leigh syndrome was made. Many infraction images not conforming to the vessel region were observed upon a brain MRI which was performed at 26 years of age, thus leading to her being diagnosed with MELAS as a complication. Upoon bibliographical consideration, it was speculated that the clinical features of MELAS/Leigh overlap syndrome clearly differ from Leigh syndrome in terms of age of onset, symptoms, and prognosis. Pleiotropic genetic factors including heteroplasmy were presumed to be involved in the diverse phenotype of overlap syndrome.
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Potestio CP, Check JH, Mitchell-Williams J. Improvement in symptoms of the syndrome of mitochondrial encephalopathy, lactic acidosis, and stroke-like symptoms (MELAS) following treatment with sympathomimetic amines--possible implications for improving fecundity in women of advanced reproductive age. CLIN EXP OBSTET GYN 2014; 41:343-345. [PMID: 24992791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE To evaluate the efficacy of sympathomimetic amine therapy on a mitochondrial abnormality known as the mitochondrial encephalopathy lactic acidosis and stroke-like symptoms syndrome (MELAS syndrome). MATERIALS AND METHODS Dextroamphetamine sulfate 15 mg extended release capsule was prescribed to a woman with a 25 year history of MELAS syndrome refractory to most other therapies. RESULTS Within one month of therapy the woman noticed considerable improvement in her chronic fatigue, pain, and edema. CONCLUSIONS The MELAS syndrome is thus another condition to add to the list of various chronic refractory disorders that improve considerably after dextroamphetamine therapy. This is the first mitochondrial disorder shown to improve with sympathomimetic amines which could suggest that dextroamphetamine could prove useful in decreasing the risk of aneuploidy in women of advanced reproductive age.
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Sudo A, Sano H, Kawamura N. [Determination of the critical time point for efficacy of L-arginine infusion therapy in a case of MELAS with frequent stroke-like episodes]. No To Hattatsu 2014; 46:39-43. [PMID: 24620430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes) is the most representative subtype of mitochondrial diseases. Administration of L-arginine (L-Arg) or a precursor of nitric oxide (NO) has been proposed as a promising medication for MELAS because one of the pathophysiological mechanisms is supposedly a decreased capacity for NO-dependent vasodilation. We experienced a girl with MELAS and frequent stroke-like episodes who was treated with L-Arg infusion. We evaluated the efficacy of L-Arg infusion therapy based on whether her headache and nausea were disappeared and neurological symptoms were improved within 24 hours of L-Arg administration. L-Arg infusions were effective in all four episodes when the treatment was started within 4 hours of the onset of stroke-like episodes. On the other hand, the infusion was effective in only one out of five episodes when the medication was delayed by more than 4 hours after the onset. Furthermore, the early administration of L-Arg resulted in better outcomes regarding new lesions determined by brain MRI. Our data suggest that L-Arg infusion may be most effective when it is started within 4 hours of the onset of neurological symptoms in the acute phase of MELAS. The study of a large number of episodes in many patients will be needed to determine the critical time point of L-Arg administration after the onset of the acute phase of MELAS.
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Koga Y. [The treatment of mitochondrial disorders, present and future]. Nihon Rinsho 2014; 72:175-184. [PMID: 24597368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Mitochondrial disorder has an inherited multi-system mitochondrial dysfunction that often involves the nervous, endocrine, renal and cardiac system. Although many molecular and cellular mechanisms leading to mitochondrial cytopathy have been discovered, clinical management of the disorders remains largely supportive. Many therapeutic drugs and reagents have been published effective in the past 20 years, however, none of those have been approved their efficacy by a double blind randomized placebo-controlled, or open labeled trial. In this review, we describe the current situation for developing the therapeutic drugs in mitochondrial disorders by clinical trial registry. We also describe the investigator-mediated clinical trial of L-arginine, and taurin for MELAS, and new project for developing the therapeutic drug of sodium pyruvate for lactic acidosis associated with mitochondrial disorders in Japan.
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Affiliation(s)
- Yasutoshi Koga
- Department of Pediatrics and Child Health, Kurume University School of Medicine
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Tsujikawa K, Yokoi S, Yasui K, Hasegawa Y, Hoshiyama M, Yanagi T. [Effectiveness of midazolam for L-arginine-resistant headaches during stroke-like episodes in MELAS: a case report]. Rinsho Shinkeigaku 2014; 54:882-887. [PMID: 25420561 DOI: 10.5692/clinicalneurol.54.882] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 14-year-old girl was referred to us with severe migraine-like headaches associated with vomiting and right homonymous hemianopsia. On admission, MRI examination showed high signals in the left occipital cortex and subcortex on T2-weighted images, without reduction of apparent diffusion coefficient suggestive of cerebral infarction. Her EEG demonstrated periodic sharp waves in the left posterior region, and laboratory tests revealed she had increased levels of lactic and pyruvic acid both in blood plasma and CSF. Gene analysis confirmed mitochondrial DNA A3243G mutation. Based on this data, we diagnosed her as having mitochondrial myopathy, encephalopathy, lactic acidosis and a stroke-like episode (MELAS). L-arginine infusion was unsuccessful for her severe headaches, which remained prolonged. She received a low dose (0.05 mg/kg/h) midazolam infusion, resulting in immediate improvement and the disappearance of headaches and abnormal EEG findings. By the age of 18, she had been readmitted eight times for stroke-like episodes accompanied by headaches. While L-arginine infusions alleviated her headaches when administered on day 1 of her episodes, they were not effective when started on or after day 2. Her L-arginine-resistant headaches were relieved by midazolam. Although the pathogenesis of headaches in MELAS is still unknown, neuronal hyperexcitability and trigeminovascular activation are considered important. Midazolam may play a role in suppressing neuronal hyperexcitability and trigeminovascular activation. Treatment with midazolam is advisable for headaches in patients with MELAS, in the event that L-arginine therapy is unsuccessful.
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Affiliation(s)
- Koyo Tsujikawa
- Department of Neurology, Nagoya Daini Red Cross Hospital
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El-Hattab AW, Emrick LT, Craigen WJ, Scaglia F. Citrulline and arginine utility in treating nitric oxide deficiency in mitochondrial disorders. Mol Genet Metab 2012; 107:247-52. [PMID: 22819233 DOI: 10.1016/j.ymgme.2012.06.018] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Revised: 06/30/2012] [Accepted: 06/30/2012] [Indexed: 12/20/2022]
Abstract
Mitochondrial diseases arise as a result of dysfunction of the respiratory chain, leading to inadequate ATP production required to meet the energy needs of various organs. On the other hand, nitric oxide (NO) deficiency can occur in mitochondrial diseases and potentially play major roles in the pathogenesis of several complications including stroke-like episodes, myopathy, diabetes, and lactic acidosis. NO deficiency in mitochondrial disorders can result from multiple factors including decreased NO production due to endothelial dysfunction, NO sequestration by cytochrome c oxidase, NO shunting into reactive nitrogen species formation, and decreased availability of the NO precursors arginine and citrulline. Arginine and citrulline supplementation can result in increased NO production and hence potentially have therapeutic effects on NO deficiency-related manifestations of mitochondrial diseases. Citrulline is a more efficient NO donor than arginine as it results in a greater increase in de novo arginine synthesis, which plays a major role in driving NO production. This concept is supported by the observation that the three enzymes responsible for recycling citrulline to NO (argininosuccinate synthase and lyase, and nitric oxide synthase) function as a complex that can result in compartmentalizing NO synthesis and channeling citrulline efficiently to NO synthesis. Clinical research evaluating the effect of arginine and citrulline in mitochondrial diseases is limited to uncontrolled open label studies demonstrating that arginine administration to subjects with MELAS syndrome results in improvement in the clinical symptoms associated with stroke-like episodes and a decrease in the frequency and severity of these episodes. Therefore, controlled clinical studies of the effects of arginine or citrulline supplementation on different aspects of mitochondrial diseases are needed to explore the potential therapeutic effects of these NO donors.
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Affiliation(s)
- Ayman W El-Hattab
- Medical Genetics Section, Department of Pediatrics, The Children's Hospital at King Fahad Medical City and King Saud bin Abdulaziz University for Health Science, Riyadh, Kingdom of Saudi Arabia
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Abstract
MELAS is the most dominant clinical features among mitochondrial disorders. However the natural course of MELAS has not been clarified yet. In order to elucidate the natural course of MELAS, we have done the Japanese Cohort study on MELAS. By the age of onset, we divided MELAS into two subgroups, a juvenile form (onset is less than 18 years of age) and an adult form (onset is more than 18 years of age). Juvenile form is significantly different from adult form not only in the mean age of onset, but the mean age of death and survival rate (juvenile has 3.2 times higher chance of death than adult). Our date indicate that juvenile form of MELAS is more severe and poor prognosis than those seen in adult form. Based on the hypothesis that MELAS is caused by impaired vasodilation in an intracerebral artery, we evaluated the effects of administering L-arginine, a nitric oxide precursor. Patients were administered L-arginine intravenously at acute phase, or per orally at interictal phase. L-arginine infusions significantly improved all stroke-like symptoms suggesting stroke within 30 min, and oral administration significantly decreased frequency and severity of stroke-like episodes. L-arginine therapy showed promise in treating stroke-like episodes in MELAS.
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Affiliation(s)
- Yasutoshi Koga
- Department of Pediatrics and Child Health, Kurume University School of Medicine
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Hirata K, Akita Y, Povalko N, Nishioka J, Yatsuga S, Matsuishi T, Koga Y. Effect of L-arginine on synaptosomal mitochondrial function. Brain Dev 2008; 30:238-45. [PMID: 17889473 DOI: 10.1016/j.braindev.2007.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Revised: 08/10/2007] [Accepted: 08/11/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Specific aim of this study is to elucidate the direct effects of L-arginine on the synaptosomal neurotransmission related to the mitochondrial respiratory function. METHODS Using isolated endbrains from wild-type mice (ICR), crude synaptosome was analyzed for their concentration of gamma-aminobutyric acid (GABA) and glutamate (Glu) with/without addition of L-arginine. We analyzed the contents of releasing amino acids evoked by high potassium condition and uptake of them in three separated fractions (cytosol, vesicles, and intact mitochondria). The oxygen consumption was also measured by oxygen electrode. RESULTS The entire uptakes of GABA and Glu were inhibited by rotenone (about 30 nmol/mg protein) with dose-dependent manner and showed a plateau at about 70% of total uptake. L-arginine inhibited the uptake of Glu logarithmically, however it showed no change in uptake of GABA. The contents of GABA and Glu in synaptosome were decreased in the presence of L-arginine. L-arginine enhanced the respiration of state II by succinate on synaptosomal respiration, although the respiration of synaptosomal mitochondrial fraction and the respiratory chains enzyme activities were almost unaffected by L-arginine. In the presence of rotenone, L-arginine decreased the uptake of Glu without changing the uptake of GABA, increased the releasing of GABA, and may modulate the excitability of neuronal state on the cytosol, cytomembrane, and/or organelles except for mitochondria. CONCLUSIONS L-arginine may modulate excitation by neurotransmitters at nerve endings, in relation to potentiated respiratory metabolism of succinate in synaptosomes. Such effects might contribute to alleviation of stroke-like symptoms in MELAS.
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Affiliation(s)
- Koji Hirata
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Fukuoka, Japan
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Chen JC, Tsai TC, Liu CS, Lu CT. Acute hearing loss in a patient with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS). Acta Neurol Taiwan 2007; 16:168-172. [PMID: 17966957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) syndrome is a rare congenital disorder of mitochondrial DNA. Patients with this syndrome may present acute onset of sensorineural hearing loss, which is genetic in origin. An impression of the MELAS syndrome is favored because hearing loss is part of the syndrome for some patients with epilepsy. We report a 20-year-old man who suffered from acute onset of bilateral hearing loss with epilepsy and two stroke-like events which recovered without any sequela. Epilepsy with complex partial seizures was controlled by antiepileptic drugs. Brain magnetic resonance images showed high signal lesions in bilateral temporal lobes. Serum levels of pyruvate and lactate were elevated. Muscle biopsy showed ragged-red fibers and molecular genetic study showed a point mutation of the mitochondrial A3243G gene. Mitochondrial disease with the MELAS syndrome was diagnosed and then he was treated with Co-enzyme Q10 and carnitine. The symptoms recovered gradually.
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Affiliation(s)
- Jui-Cheng Chen
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
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Koga Y, Akita Y, Nishioka J, Yatsuga S, Povalko N, Katayama K, Matsuishi T. MELAS and l-arginine therapy. Mitochondrion 2007; 7:133-9. [PMID: 17276739 DOI: 10.1016/j.mito.2006.11.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Accepted: 10/24/2006] [Indexed: 10/23/2022]
Abstract
We investigated the endothelial function in MELAS patients and also evaluated the therapeutic effects of L-arginine. Concentrations of L-arginine during the acute phase of MELAS were significantly lower than in control subjects. L-arginine infusions significantly improved all symptoms suggesting stroke within 30 min, and oral administration significantly decreased frequency and severity of stroke-like episodes. Flow-mediated dilation (FMD) in patients showed a significant decrease than those in the controls. Two years of oral supplementation of L-arginine significantly improved endothelial function to the control levels and was harmonized with the normalized plasma levels of L-arginine in patients. L-arginine therapy showed promise in treating stroke-like episodes in MELAS.
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Affiliation(s)
- Yasutoshi Koga
- Department of Pediatrics and Child Health, Kurume University School of Medicine, 67 Asahi Machi, Kurume, Fukuoka 830-0011, Japan.
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Abstract
The authors evaluated endothelial function in patients with MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke) by flow-mediated vasodilation (FMD) and found a significant decrease vs controls. Two years of supplementation with oral l-arginine, a nitric oxide precursor, significantly improved endothelial function to control levels and was harmonized with the normalized plasma levels of l-arginine in patients. l-Arginine therapy improved endothelial dysfunction and showed promise in treating strokelike episodes in MELAS.
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Affiliation(s)
- Y Koga
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Fukuoka, Japan.
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Kaufmann P, Engelstad K, Wei Y, Jhung S, Sano MC, Shungu DC, Millar WS, Hong X, Gooch CL, Mao X, Pascual JM, Hirano M, Stacpoole PW, DiMauro S, De Vivo DC. Dichloroacetate causes toxic neuropathy in MELAS: a randomized, controlled clinical trial. Neurology 2006; 66:324-30. [PMID: 16476929 DOI: 10.1212/01.wnl.0000196641.05913.27] [Citation(s) in RCA: 237] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy of dichloroacetate (DCA) in the treatment of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS). BACKGROUND High levels of ventricular lactate, the brain spectroscopic signature of MELAS, correlate with more severe neurologic impairment. The authors hypothesized that chronic cerebral lactic acidosis exacerbates neuronal injury in MELAS and therefore, investigated DCA, a potent lactate-lowering agent, as potential treatment for MELAS. METHODS The authors conducted a double-blind, placebo-controlled, randomized, 3-year cross-over trial of DCA (25 mg/kg/day) in 30 patients (aged 10 to 60 years) with MELAS and the A3243G mutation. Primary outcome measure was a Global Assessment of Treatment Efficacy (GATE) score based on a health-related event inventory, and on neurologic, neuropsychological, and daily living functioning. Biologic outcome measures included venous, CSF, and 1H MRSI-estimated brain lactate. Blood tests and nerve conduction studies were performed to monitor safety. RESULTS During the initial 24-month treatment period, 15 of 15 patients randomized to DCA were taken off study medication, compared to 4 of 15 patients randomized to placebo. Study medication was discontinued in 17 of 19 patients because of onset or worsening of peripheral neuropathy. The clinical trial was terminated early because of peripheral nerve toxicity. The mean GATE score was not significantly different between treatment arms. CONCLUSION DCA at 25 mg/kg/day is associated with peripheral nerve toxicity resulting in a high rate of medication discontinuation and early study termination. Under these experimental conditions, the authors were unable to detect any beneficial effect. The findings show that DCA-associated neuropathy overshadows the assessment of any potential benefit in MELAS.
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Affiliation(s)
- P Kaufmann
- Department of Neurology, Columbia University, New York 10032, USA.
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Curtò N, Tremolizzo L, Mattavelli L, Piatti ML, Marzorati L, Guerra L, Grassi MG, Ferrarese C. A case of Melas (A3243G) on chronic dichloroacetate treatment. Eur Neurol 2006; 55:37-8. [PMID: 16479117 DOI: 10.1159/000091424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Accepted: 10/12/2005] [Indexed: 11/19/2022]
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Nakano K, Tarashima M, Tachikawa E, Noda N, Nakayama T, Sasaki K, Mizoguchi E, Matsuzaki M, Osawa M. Platelet mitochondrial evaluation during cytochrome c and dichloroacetate treatments of MELAS. Mitochondrion 2005; 5:426-33. [PMID: 16290150 DOI: 10.1016/j.mito.2005.10.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2005] [Revised: 09/13/2005] [Accepted: 10/12/2005] [Indexed: 10/25/2022]
Abstract
We hypothesized that serial changes in platelet (PLT) mitochondrial enzyme (ME) activities might correspond to the effects of medications for mitochondrial encephalomyopathy and stroke-like episodes (MELAS). Cytochrome c and sodium dichloroacetate (DCA) were given to a 7-year-old girl with MELAS who had an A3243G mitochondrial DNA mutation. The effects were evaluated with whole PLT-ME assays, developed by our group, using a microplate-reader. During cytochrome c treatment, complex II+III (II+III), complex IV (IV) and citrate synthase (CS) activities showed gradual but statistically significant decrease. II+III activity dropped below normal. II+III/CS activity was initially below normal, followed by a transient improvement, then decreased again before the appearance of central nervous system symptoms. II+III, IV, II+III/CS and IV/CS activities reached their lowest levels in association with a stroke-like episode, then increased with DCA treatment. Our results suggest that progressive mitochondrial dysfunction may occur before the stroke-like episodes in MELAS and that DCA treatment may increase mitochondrial activities. Our whole PLT-ME assay system may be useful for serially evaluating mitochondrial functions in relation to clinical symptoms.
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Affiliation(s)
- Kazutoshi Nakano
- Department of Pediatrics, Tokyo Women's Medical University, Shinjuku-ku, Tokyo 162-8666, Japan.
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Abstract
Based on the hypothesis that mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes (MELAS) are caused by impaired vasodilation in an intracerebral artery, the authors evaluated the effects of administering l-arginine, a nitric oxide precursor. Patients were administered L-arginine intravenously at the acute phase or orally at the interictal phase. L-arginine infusions significantly improved all strokelike symptoms, suggesting that oral administration within 30 minutes of a stroke significantly decreased frequency and severity of strokelike episodes.
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Affiliation(s)
- Y Koga
- Department of Pediatrics and Child Health, Kurume University School of Medicine, 67 Asahi-Machi, Kurume City, Fukuoka 830-0011, Japan.
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Maeda K, Tatsumi M, Tahara M, Murata Y, Kawai H, Yasuda H. [A case of stroke-like episode of MELAS of which progressive spread would be prevented by edaravone]. Rinsho Shinkeigaku 2005; 45:416-21. [PMID: 16022465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
A thirty-two-year-old woman who had been diagnosed MELAS with 3243A > G mutation presented headache, nausea, decreased bilateral visual acuity, and topographical disturbance on January 1 in 2002. Although brain CT showed no fresh lesion, recurrence of stroke-like episode was considered. Immediately, she was treated with ubiquinone (210 mg/day, p.o.) and tocopherol nicotinate (300 mg/day, p.o.). She became confused on the fifth day. Diffusion weighted- and T2 weighted-MRI revealed appearance of hyperintense lesion at the right occipital lobe. We started edaravone infusion (30 mg, twice a day, div.) for two weeks with informed consent from her family. On 13th day her consciousness was improved. Edema and signal intensity of the lesion were decreased on MRI with minimal spread to the parietal lobe. She discharged on the 30th day with marked visual field loss, hemispatial neglect, and topographical amnesia. MRI after four months showed remarkable atrophy of the right occipital region. In our department, five stroke-like episodes including this case were treated with ubuiquinone and tocopherol nicotinate. This regimen was effective in prevention of progressive spread of lesions only in two episodes. Edaravone is radical scavenger used in acute cerebral infarction. Progressive spread into the neighboring regions is one of characteristics of MELAS, although its precise mechanisms are not well known. Oxidative stress induced by released free radicals through mitochondrial dysfunction might be one of factors and edaravone would make an effect through blockage of the free radicals. Edaravone could not rescue neurons in the initial lesion. Although more numbers of cases are needed to establish the effect of edaravone on MELAS, it could minimize the neurological deficits after stroke-like episode of MELAS.
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Affiliation(s)
- Kengo Maeda
- Division of Neurology, Department of Medicine, Shiga University of Medical Science
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Abstract
L-citrulline, classified as a nonessential amino acid, is synthesized predominantly via Delta-1-pyrroline carboxylate synthase in the endothelial cells of the small intestine. In mammals, small quantities of citrulline are also produced in nitric oxide synthase-expressing cells. Considering the fact that the enzymes involved in the endogenous synthesis of L-citrulline are all located in the mitochondria and the fact that citrulline is a component of the citrulline-nitric oxide (NO) cycle, we hypothesized that the distinct clinical, biochemical, and morphological characteristics of MELAS, a maternally inherited mitochondrial disorder, might be due to alterations in nitric oxide homeostasis. Analysis of serum from MELAS patients showed that levels of plasma arginine were similar in both patients and in controls. However, levels of citrulline in MELAS patients were significantly lower than in controls, and there was a clear inverse correlation between arginine and citrulline levels in these patients. We found no correlation between the level of heteroplasmy and the plasma levels of either arginine or citrulline. We discuss the depressed citrulline levels in MELAS patients, who have an unusual and paradoxical pattern of vascular respiratory chain expression, in the context of NO homeostasis.
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Affiliation(s)
- Ali Naini
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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Mori M, Yamagata T, Goto T, Saito S, Momoi MY. Dichloroacetate treatment for mitochondrial cytopathy: long-term effects in MELAS. Brain Dev 2004; 26:453-8. [PMID: 15351081 DOI: 10.1016/j.braindev.2003.12.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2003] [Revised: 12/26/2003] [Accepted: 12/26/2003] [Indexed: 11/19/2022]
Abstract
The long-term effects of the sodium salt of dichloroacetic acid (DCA) were evaluated in four patients with mitochondrial encephalomyelopathy with lactic acidosis and stroke-like episodes (MELAS) carrying A3243G mutation. Oral administration of DCA in MELAS patients was followed for an average of 5 years 4 months. Serum levels of lactate and pyruvate were maintained at around 10 and 0.6 mg/dl, respectively. Serum levels of DCA were 40-136 microg/ml. Symptoms responding to treatment included persistent headache, abdominal pain, muscle weakness, and stroke-like episodes. In contrast, no improvements in mental status, deafness, short stature, or neuroelectrophysiological findings were observed. Adverse effects included mild liver dysfunction in all patients, hypocalcemia in three and peripheral neuropathy in one. None of these adverse events was severe enough to require discontinuation of treatment. To determine suitable indications for DCA therapy, analysis of many more patients who have undergone DCA administration is required.
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Affiliation(s)
- Masato Mori
- Department of Pediatrics, Jichi Medical School, 3311-1 Yakushiji, Minamikawachi, Tochigi 329-0498, Japan.
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Kubota M, Sakakihara Y, Mori M, Yamagata T, Momoi-Yoshida M. Beneficial effect of L-arginine for stroke-like episode in MELAS. Brain Dev 2004; 26:481-3; discussion 480. [PMID: 15351086 DOI: 10.1016/j.braindev.2004.01.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2003] [Revised: 01/05/2004] [Accepted: 01/24/2004] [Indexed: 10/26/2022]
Abstract
We here reported the clinical course and therapeutic details of a 16-year-old girl with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) who had had five stroke-like episodes (two episodes were clinically mild, while the three subsequent episodes were severe). Among the three episodes, the symptoms improved earliest and magnetic resonance spectroscopy abnormality was minimal when given L-arginine in addition to prednisolone, glycerol and edalavone. L-arginine administration during the acute phase of MELAS might be a potential therapy to reduce brain damage due to mitochondrial dysfunction.
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Affiliation(s)
- Masaya Kubota
- Department of Pediatrics, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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Berbel-Garcia A, Barbera-Farre JR, Etessam JP, Salio AM, Cabello A, Gutierrez-Rivas E, Campos Y. Coenzyme Q 10 Improves Lactic Acidosis, Strokelike Episodes, and Epilepsy in a Patient With MELAS (Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis, and Strokelike episodes). Clin Neuropharmacol 2004; 27:187-91. [PMID: 15319706 DOI: 10.1097/01.wnf.0000137862.67131.bf] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Mitochondrial encephalomyopathies encompass a group of disorders that have impaired oxidative metabolism in skeletal muscles and central nervous system. Many compounds have been used in clinical trials on mitochondrial diseases, but the outcomes have been variable. It remains controversial whether treatment of mitochondrial diseases with coenzyme Q 10 is effective. This paper describes a case of mitochondrial myopathy, encephalopathy, lactic acidosis, strokelike episodes, and exercise intolerance successfully treated with coenzyme Q 10. Efficacy of this therapy in this patient is correlated to control of lactic acidosis and serum creatine kinase levels. Disappointingly, larger studies with coenzyme Q 10 failed to demonstrate a clear beneficial effect on the entire study population with regard to clinical improvement or several parameters of the oxidative metabolism. They suggest that the use of coenzyme Q in treatment of mitochondrial diseases should be confined to protocols. There is a confounding variation in phenotype and genotype, and the natural history of the disorders in individual patients is not accurately predictable. The unpredictable a priori efficacy of therapy suggests that a long-term trial of oral coenzyme Q may be warranted.
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Affiliation(s)
- Angel Berbel-Garcia
- Department of Neurology, Hospital Mancha Centro, Alcazar de San Juan, Ciudad Real, Spain.
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Abstract
We present a case report of a 27-year-old man with MELAS, who presented with general convulsions and left flaccid hemiparesis. Anticonvulsant drugs failed to achieve complete control of his convulsions. A good response to oral administration of succinate has been maintained for more than 30 months, with no recurrence of any stroke-like episode. Succinate therapy may have potential for treatment of uncontrolled convulsive MELAS patients.
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Affiliation(s)
- Hiroaki Oguro
- Third Department of Internal Medicine, Shimane University School of Medicine, 89-1 Enya-cho, Izumo, Shimane 693-8501
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Affiliation(s)
- Akira Sudo
- Department of Child Neurology, National Center Hospital for Mental, Nervous, and Muscular Disorders, National Center of Neurology and Psychiatry, Tokyo, Japan.
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Finsterer J, Jilek K. Post-Ictal Recovery of Anarthria and Weakness in MELAS Syndrome. Eur Neurol 2004; 52:122-3. [PMID: 15319559 DOI: 10.1159/000080271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- J Finsterer
- Department of Neurology, Krankenanstalt Rudolfstiftung, Vienna, Austria.
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43
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Abstract
The mitochondrial encephalomyopathies are chronic progressive disorders affecting predominantly the neuromuscular system. Symptoms are induced by insufficient energy supply resulting from a deficiency of oxidative phosphorylation. We studied one male and four female patients with genetically proven mitochondrial encephalomyopathy. Their ages ranged from 7 to 19 years (two with Kearns-Sayre syndrome, one patient with neuronal muscle weakness, ataxia, and retinitis pigmentosa syndrome, and two patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes), using a retrospective study method. We studied the effect of creatine supplementation (0.08 g-0.35 g/kg body weight/day; 9 months to 4 years, 10 months) and measured skeletal muscle power analysis (bicycle ergometer). After creatine supplementation all patients demonstrated an increase in their maximum performance (W) (+4% - +30%; mean: +12.1%). These results indicate an improved aerobic oxidative function of mitochondria after creatine administration in patients with mitochondrial encephalomyopathies. Continuous physical exercise was improved to a greater extent than instantaneous activity.
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Affiliation(s)
- Kiyomi Komura
- Department of Pediatrics, Tokyo Women's Medical University, Japan
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Ohtsu M, Nakano K, Maeda Y, Muto A, Tsurumi E, Yazaki E, Katsumori H, Hayashi K, Osawa M. [Effects of midazolam on acute phase of stroke in two patients with mitochondrial encephalopathy, lactic acidosis and stroke-like episodes]. No To Hattatsu 2003; 35:71-4. [PMID: 12607295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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Matsuzaki M, Izumi T, Shishikura K, Suzuki H, Hirayama Y. Hypothalamic growth hormone deficiency and supplementary GH therapy in two patients with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes. Neuropediatrics 2002; 33:271-3. [PMID: 12536371 DOI: 10.1055/s-2002-36742] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Two pediatric patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes were diagnosed with growth hormone deficiency with the primary lesion identified as the growth hormone-releasing factor producing cells of the hypothalamus. Stimulation tests with insulin, levodopa and sleep did not overcome the deficient pattern of growth hormone secretion. By comparison, the growth hormone-releasing factor stimulation test generated a normal growth hormone response in these two patients. Growth hormone supplementary therapy was effective in terms of growth gain without adverse effects.
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Affiliation(s)
- M Matsuzaki
- Department of Pediatrics, Tokyo Women's Medical University, School of Medicine, Tokyo, Japan.
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Barisic N, Bernert G, Ipsiroglu O, Stromberger C, Müller T, Gruber S, Prayer D, Moser E, Bittner RE, Stöckler-Ipsiroglu S. Effects of oral creatine supplementation in a patient with MELAS phenotype and associated nephropathy. Neuropediatrics 2002; 33:157-61. [PMID: 12200746 DOI: 10.1055/s-2002-33679] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
An 18-year-old male patient with MELAS phenotype and 2 previous episodes of cerebral stroke, recurrent seizures and nephropathy, was treated with creatine monohydrate after the acute onset of psychomental regression and changing states of somnolence and aggressive and agitated behaviour. These symptoms disappeared completely after 4 weeks of treatment with creatine after which the patient regained all his previous mental abilites. Brain (white matter) proton magnetic resonance spectroscopy (chemical shift imaging) performed at 6 and 12 months of treatment showed lactic acid (Lac) accumulation and high creatine (Cr) levels in relation to choline-containing compounds (Cho). Urinary creatinine excretion as an indicator of the muscle and brain creatine pool increased upon short-term (12 days) high-dosage creatine supplementation (20 g per day) while plasma creatinine concentrations as possible indicators both of increasing creatine pool and of renal insufficiency increased during the course (28 months) of low-dosage creatine supplementation (5 g per day). Deterioration of renal function was finally indicated by urea retention and by impairment of renal creatinine clearance. These observations suggest that creatine supplementation may have a neuroprotective effect in patients with MELAS and episodes of acute mental deterioration. Adverse effects of creatine supplementation on renal function must be considered especially in patients with preexisting nephropathy.
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Affiliation(s)
- N Barisic
- Department of Pediatrics, University of Vienna, Austria
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Abstract
Nicotinamide can facilitate DNA repair by inhibiting poly(ADP-ribose) polymerase, increasing NAD levels and adjusting other related enzyme activities. This review will summarize recent work on the design of poly(ADP-ribose) polymerase inhibitors, poly(ADP-ribose) glycohydrolase inhibitors and will discuss the possible use of drugs that interact with NAD synthetic enzymes.
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Affiliation(s)
- J Yang
- School of Pharmacy, University of Southern California, 1985 Zonal Avenue, Los Angeles, California 90089, USA
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Koga Y, Ishibashi M, Ueki I, Yatsuga S, Fukiyama R, Akita Y, Matsuishi T. Effects of L-arginine on the acute phase of strokes in three patients with MELAS. Neurology 2002; 58:827-8. [PMID: 11889254 DOI: 10.1212/wnl.58.5.827] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Y Koga
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan.
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Abstract
We report a patient with MELAS treated for 24 months with idebenone and riboflavin, during which no stroke-like episodes occurred. Moreover neurological symptoms clearly improved, and a recovery of brain MRI and EEG abnormalities was observed. We conclude that the combined treatment with idebenone and riboflavin may restore the metabolic impairment in MELAS, possibly improving the long-term prognosis in these patients.
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Affiliation(s)
- A Napolitano
- Division of Neurology, Campo di Marte Hospital, I-55100 Lucca, Italy
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50
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Hattori Y, Matsuda M, Eizawa T, Nakajima K. [A case of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS), showing temporary improvement during the treatment with eicosapentaenoic acid ethyl ester]. Rinsho Shinkeigaku 2001; 41:668-72. [PMID: 11993186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
We report a 67-year-old man with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS), successfully treated with eicosapentaenoic acid ethyl ester (EPA-E) for about eight months. He showed bilateral auditory disturbance and slowly progressive gait ataxia at age 50 during treatment of diabetes mellitus (DM) with subcutaneous injection of insulin since age 29. At age 58 he manifested an acute hemiparesis of right extremities for one week with no abnormal findings on neuroradiological examinations. A permanent pacemaker was implanted at age 61 to treat frequent syncopal attacks due to complete atrioventricular block. On admission to our hospital, neurological examinations revealed dementia, auditory disturbance, severe cerebellar ataxia and mild atrophy of proximal muscles with systemic hyporeflexia. Based on a point mutation in position 3243 of mitochondrial DNA, he was diagnosed as having MELAS with severe DM, auditory disturbance and cardiac conduction block. After initiation of treatment with EPA-E at a dose of 2,700 mg/day he showed temporarily an improvement in auditory disturbance, blood glucose control and cerebellar ataxia. In objective evaluations for cerebellar ataxia, we could find significant decreases in times for 20 m walking and heel-knee patting in the ninth month, and in time for tracing of a whirl from the third to the ninth month, compared with those before treatment of EPA-E (p < 0.0001). Because EPA-E is taken into mitochondrial membranes and activates electron transmission enzyme complexes, it might be a candidate for therapy of mitochondrial encephalomyopathy, including MELAS.
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Affiliation(s)
- Y Hattori
- Department of Internal Medicine, Asama General Hospital
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