Ophthalmoplegia in Mitochondrial Disease

PURPOSE: To evaluate the classification, diagnosis, and natural course of ophthalmoplegia associated with mitochondrial disease. MATERIALS AND METHODS: Among 372 patients with mitochondrial disease who visited our hospital between January 2006 and January 2016, 21 patients with ophthalmoplegia were retrospectively identified. Inclusion criteria included onset before 20 years of age, pigmentary retinopathy, and cardiac involvement. The 16 patients who were finally included in the study were divided into three groups according to disease type: Kearns-Sayre syndrome (KSS), KSS-like, and chronic progressive external ophthalmoplegia (CPEO). RESULTS: The prevalences of clinical findings were as follows: ptosis and retinopathy, both over 80%; myopathy, including extraocular muscles, 75%; lactic acidosis, 71%; and elevated levels of serum creatine kinase, 47%. Half of the patients had normal magnetic resonance imaging findings. A biochemical enzyme assay revealed mitochondrial respiratory chain complex I defect as the most common (50%). The prevalence of abnormal muscle findings in light or electron microscopic examinations was 50% each, while that of large-scale mitochondrial DNA (mtDNA) deletions in a gene study was 25%. We compared the KSS and KSS-like groups with the CPEO patient group, which showed pigmentary retinopathy (p < 0.001), cardiac conduction disease (p=0.013), and large-scale mtDNA deletions (p=0.038). KSS and KSS-like groups also had gastrointestinal tract disorders such as abnormal gastrointestinal motility (p=0.013) unlike the CPEO group. CONCLUSION: Patients with KSS had gastrointestinal symptoms, which may indicate another aspect of systemic involvement. The presence of large-scale mtDNA deletions was an objective diagnostic factor for KSS and a gene study may be helpful for evaluating patients with KSS.

Síndrome de Kearns Sayre: reporte de dos casos / Kearns Sayre Syndrome: Report of two cases

RESUMEN El síndrome de Kearns Sayre (SKS) es una rara mitocondriopatía causada en la mayoría de los casos por deleciones en el ADN mitocondrial, usualmente no heredada y de ocurrencia espontánea. Se caracteriza por disfunción multiorgánica de manifestación antes de los veinte años de edad. Fue descrito por Thomas Kearns y George Sayre, quienes reportaron la tríada de oftalmoplejía externa, retinopatía pigmentaria y bloqueos de la conducción cardíaca, siendo esta última alteración determinante en el pronóstico, así como el número de órganos afectados. Presentamos dos casos de Síndrome de Kearns Sayre con manifestaciones clínicas oftalmológicas en su debut, asociados a debilidad muscular, similar a los casos típicos reportados en la literatura, donde la mayoría de los pacientes presentan compromiso ocular. En la literatura colombiana existen pocos reportes de este síndrome, por lo tanto, esta presentación contribuye al conocimiento de la entidad en nuestro medio, la patología presenta una triada clínica específica, pero a la vez muestra una afección multisistémica que requiere un alto índice de sospecha por parte de las especialidades a las cuales el paciente puede acceder en su cuadro inicial.

SUMMARY The Kearns-Sayre syndrome is a rare mitochondrial disease caused, in most cases by deletions in mitochondrial DNA, usually not inherited and spontaneously occurring. It is characterized by multiorganic dysfunction that typically develops before the age of twenty. Described by Thomas Kearns and George Sayre who reported a case with presence of the triad of external ophthalmoplegia, pigmentary retinopathy and cardiac conduction blocks, the latter being decisive alteration in the forecast, as well as the number of affected organs. We report two cases of Kearns-Sayre syndrome debuting with ophthalmological clinical manifestations, associated with muscle weakness, similar to typical cases reported in the literature where most patients have eye involvement. The Colombian literature there are very few reported cases of this syndrome, so this presentation contributes to the knowledge of this entity in our environment, taking into account that this disease presents a specific clinical triad but both shows multisystem condition, requiring a high index of suspicion on the part of various specialties to which the patient can be accessed.

Kearns-sayre Syndrome Treated with Permanent Pacemaker Insertion for Complete Atrioventricular Block / 고신대학교의과대학학술지

Kearns-Sayre syndrome (KSS) is a rare multisystem mitochondrial disorder associated with progressive external ophthalmoplegia, atypical pigmentary degeneration of the retina, and complete heart block. KSS can lead to a risk of sudden death because of the potential progression of conduction abnormalities such as right or left bundle branch block or complete atrioventricular (AV) block. Here we describe the case of a KSS patient with type I diabetes who experienced syncope in the presence of complete AV block, confirmed by muscular biopsy.

Implante coclear na síndrome Kearns-Sayre: estudo de caso de irmãs gêmeas / Cochlear implant in Kearns-Sayre syndrome: case study of twin sisters

RESUMO A deficiência auditiva pode estar relacionada com diversos fatores, entre eles, a perda auditiva decorrente de determinadas síndromes genéticas. A síndrome Kearns-Sayre é caracterizada por mutações no DNA (deoxyribonucleic acid) mitocondrial, responsável pela produção de energia (trifosfato de adenosina - ATP), que é de extrema importância para o desenvolvimento de estruturas que dela necessitam, como a cóclea. O caso foi acompanhado no hospital, desde o ano 2000, devido à característica progressiva da perda auditiva constatada nos exames audiológicos e nos achados em casos relacionados à síndrome. A intervenção com os aparelhos de amplificação sonora individual (AASI) se mostrou pouco benéfica para a boa comunicação oral de uma das pacientes, que passou a ter o diagnóstico de perda auditiva profunda bilateral. Assim, após discussões em reuniões clinicas, a equipe optou pela indicação do implante coclear para a paciente, segundo os critérios atuais para indicação desta cirurgia, e com o qual obteve bons resultados. Sua irmã gêmea, que apresentou bons resultados com AASI, continuará em acompanhamento audiológico, para se verificar a evolução do caso e discutir uma nova conduta, caso necessário. Pacientes com suspeita, ou diagnóstico de síndrome Kearns-Sayre devem buscar o diagnóstico audiológico, pois se trata de uma possível perda auditiva progressiva, sendo necessária a reabilitação com o uso de dispositivos auditivos. Manter a comunicação oral é de extrema importância, pois, nestes casos, outras funções serão prejudicadas, como o tônus muscular e a visão.

ABSTRACT Hearing impairment may be related to several factors, including hearing loss due to certain genetic syndromes. Kearns-Sayre syndrome is characterized by mutations in mitochondrial DNA (deoxyribonucleic acid), responsible for energy production (adenosine triphosphate - ATP), which is extremely important for the development of structures that need it, such as the cochlea. The case was followed in the hospital, since 2000, due to the progressive characteristic of the hearing loss observed in the audiological examinations and the findings in cases related to the syndrome. The intervention with individual sound amplification devices (AASI) proved to be of little benefit to the good oral communication of one of the patients, who was diagnosed as having bilateral profound hearing loss. Thus, after discussions at clinical meetings, the team opted for the indication of the cochlear implant for the patient, according to the current criteria for indication of this surgery, and with which it obtained good results. Her twin sister, who presented good results with AASI, will continue to undergo audiological follow-up, to verify the evolution of the case and discuss a new conduct, if necessary. Patients with suspected or diagnosed Kearns-Sayre syndrome should seek the audiological diagnosis, since it is a possible progressive hearing loss, requiring rehabilitation with the use of hearing devices. Maintaining oral communication is extremely important because in these cases other functions will be impaired, such as muscle tone and vision.

Clinical and Brain Magnetic Resonance Imaging Features in a Cohort of Chinese Patients with Kearns-Sayre Syndrome / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Kearns-Sayre syndrome (KSS) is a mitochondrial DNA (mtDNA) deletion disorder characterized by a triad of onset before 20 years of age, ophthalmoplegia, and pigmentary retinopathy. The heart and central nervous system are commonly involved. We summarized clinical and brain magnetic resonance imaging (MRI) features of a cohort of Chinese KSS patients.</p><p><b>METHODS</b>Nineteen patients confirmed by muscle biopsy and mtDNA analysis were enrolled. We examined clinical profiles, mainly focusing on changes in electrocardiogram (ECG) and brain MRI. The correlation between genotype and phenotype was statistically analyzed.</p><p><b>RESULTS</b>The mean age of onset was 9.6 ± 4.3 years, with all developing the classic triad at the time of diagnosis. Heart conduction block was detected in 63.2%, with four initially presenting as bundle branch block and developing into complete atrioventricular block over 3-72 months. Brain MRI showed symmetric high-T2 signals in 100% of cerebral and cerebellar white matter, as well as brainstem, 46.7% of basal ganglia, and 53.3% of thalamus. There were two patterns of cerebral white matter involvements, one with selective subcortical U-fibers and the other with periventricular white matter. The size of mtDNA deletion did not significantly correlate with age of onset or percentage of ragged blue fibers on muscle pathology.</p><p><b>CONCLUSIONS</b>The clinical features of KSS evolve dynamically, affecting the cardiac conduction system predominantly, highlighting the significance of ECG monitoring. Brain MRI showed changes involving both the white matter and deep gray nuclei. Clinical presentation or severity of muscle pathological changes is not related to the size of mtDNA deletions.</p>

Treatment of Eyelid Ptosis due to Kearns-Sayre Syndrome Using Frontalis Suspension

Blepharoptosis is a common indication for surgery in plastic surgery units, yet its possible underlying pathology frequently remains unidentified. A 52-year-old man with a 20-year history of progressive bilateral ptosis (right>left) presented with recurrent ptosis of both eyes; he had undergone an operation on the levator aponeurosis 12 years prior. Due to the suspicion of an underlying disease, he was evaluated further. Chronic progressive external ophthalmoplegia in transition to the more severe syndromic variant Kearns-Sayre syndrome, a mitochondrial disorder causing myopathy, was diagnosed. The patient was treated with coenzyme Q10, and he underwent ptosis surgery on both eyes. This case illustrates a potentially multi-systemic disease that was diagnosed by a further evaluation of a common symptom, in this case worsening blepharoptosis. Awareness of myopathic symptoms is necessary to prevent overlooking serious yet improvable conditions.

Obstetric anesthesia considerations in Kearns-Sayre syndrome: a case report / 대한마취과학회지

Kearns-Sayre syndrome (KSS) is a rare mitochondrial myopathy that usually develops before 20 years of age. It demonstrates multisystemic involvement with a triad of cardinal features: progressive ophthalmoplegia, pigmentary retinopathy, and cardiac conduction abnormalities. In addition, patients might have cerebellar ataxia, a high content of protein in the cerebrospinal fluid, proximal myopathy, multiple endocrinopathies, and renal tubular acidosis. We herein report the successful obstetric analgesic and anesthetic management of a 28-year-old parturient patient with KSS who required labor analgesia and proceeded to deliver by cesarean section. We extrapolate that regional analgesia/anesthesia might be beneficial for reducing the metabolic demands associated with the stress and pain of labor in patients with KSS. Efficient postoperative analgesia should be provided to decrease oxygen requirements.

Obstetric anesthesia considerations in Kearns-Sayre syndrome: a case report / 대한마취과학회지

Kearns-Sayre syndrome (KSS) is a rare mitochondrial myopathy that usually develops before 20 years of age. It demonstrates multisystemic involvement with a triad of cardinal features: progressive ophthalmoplegia, pigmentary retinopathy, and cardiac conduction abnormalities. In addition, patients might have cerebellar ataxia, a high content of protein in the cerebrospinal fluid, proximal myopathy, multiple endocrinopathies, and renal tubular acidosis. We herein report the successful obstetric analgesic and anesthetic management of a 28-year-old parturient patient with KSS who required labor analgesia and proceeded to deliver by cesarean section. We extrapolate that regional analgesia/anesthesia might be beneficial for reducing the metabolic demands associated with the stress and pain of labor in patients with KSS. Efficient postoperative analgesia should be provided to decrease oxygen requirements.

Síndrome de Kearns-Sayre, presentación de un caso clínico / Kearns-Sayre Syndrome

El síndrome de Kearns Sayre es una mitocondriopatía caracterizada por disfunciones multiorgánicas que clásicamente se desarrolla antes de los veinte años de edad. Esta rara enfermedad fue descrita en 1958 por Thomas P. Kearns y George P. Sayre a través del reporte de un caso que representaba la triada clínica de oftalmoplejia externa, retinopatía pigmentaria y bloqueos de la conducción cardíaca; siendo esta última alteración la que determina el pronóstico. Aún no se cuenta con un tratamiento curativo para esta enfermedad. En este artículo presentamos el caso clínico de una paciente de 39 años a la que se realizó el diagnóstico de Kearns-Sayre.

Vascular Hyperemia and Crossed Cerebellar Diaschisis in MELAS Patient Presented as Stroke-Like Episode and Seizure

Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is one of the mitochondrial disorders that can present as a stroke-like episode or seizure. Although the pathophysiology of MELAS remains inconclusive, the main possibilities are thus far thought to be mitochondrial cytopathy and angiopathy. This case report describes a 61-year-old woman diagnosed with MELAS who presented simultaneously with vascular hyperemia and crossed cerebellar diaschisis.

Vascular Hyperemia and Crossed Cerebellar Diaschisis in MELAS Patient Presented as Stroke-Like Episode and Seizure

Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is one of the mitochondrial disorders that can present as a stroke-like episode or seizure. Although the pathophysiology of MELAS remains inconclusive, the main possibilities are thus far thought to be mitochondrial cytopathy and angiopathy. This case report describes a 61-year-old woman diagnosed with MELAS who presented simultaneously with vascular hyperemia and crossed cerebellar diaschisis.

Hallazgos en la tomografía de coherencia óptica macular y de electrofisiología en un paciente con síndrome de Kearns-Sayre y anemia de Fanconi / Findings in macular optical coherence tomography and electrophysiology in a patient with Kearns-Sayre syndrome and Fanconi anemia

Introducción. El síndrome de Kearns-Sayre, descrito por primera vez en 1958, es un raro trastorno del ADN mitocondrial, con incidencia desconocida y progresión lenta que afecta al sistema nervioso central, los músculos y los órganos endocrinos. Entre las características clínicas típicas se encuentran: distrofia atípica pigmentaria de la retina, oftalmoplejia externa progresiva y bloqueo cardíaco. Presentación de caso. Se presenta el caso de una paciente de 10 años de edad, atendida en nuestro Departamento de Retina, con diagnóstico de síndrome de Kearns-Sayre mediante resonancia magnética (RM). Se describen los hallazgos de la tomografía de coherencia óptica macular y de las pruebas de electrofisiología, hallazgos tomográficos no descritos anteriormente en la literatura científica. Conclusión. La tomografía de coherencia óptica macular reveló atenuación de la línea de hiperreflexión que corresponde a la membrana limitante externa, con pérdida de la línea de hiperreflexión que corresponde a la zona elipsoide. La tomografía de coherencia óptica macular es una herramienta útil para evaluar la extensión del daño en la retina externa, el cual fue confirmado por pruebas de electrofisiología.

Introduction. The Kearns-Sayre syndrome, first described in 1958, is a rare disorder in the mitochondrial DNA with unknown incidence and slow progression that affects the central nervous system, muscles and endocrine organs. Typical clinical features are: atypical pigmentary dystrophy of the retina, progressive external ophthalmoplegia and heart block. Case report. We report the case of a 10 years old girl attended at our retinal department, diagnosed with Kearns-Sayre syndrome by MRI. We describe the electrophysiological test and macular optical coherence tomography findings which have not been previously described in the literature. Conclusion. The macular optical coherence tomography revealed attenuation of the hyperreflectivity line corresponding to the external limiting membrane, with loss of the hyperreflectivity line corresponding to the ellipsoid zone. The macular optical coherence tomography is a helpful tool to assess the extent of the damage to the outer retina which is confirmed by electrophysiological tests.

Autosomal Dominant Type of Chronic Progressive External Ophthalmoplegia With Elevated Acetylcholine Receptor Binding Antibody

External ophthalmoplegia and ptosis are common manifestations of mitochondrial cytopathy, such as chronic progressive external ophthalmoplegia (CPEO). However, these symptoms and signs may also be presenting features of myasthenia gravis (MG). There are a few reports of CPEO with elevated acetylcholine receptor antibody (AchR-Ab). We report a case of AD-type CPEO with elevated acetylcholine receptor binding antibody. We confirmed a mutation on the SLC25A4 gene by molecular analysis.

Clinical manifestations and anesthetic management of Kearns-Sayre syndrome: A case report

Kearns-Sayre syndrome (KSS) is a mitochondrial disorder resulting in multi-system dysfunction. A 14-year-old boy with KSS underwent external levator muscle resection for correction of ptosis. There were no abnormalities on the pre-operative evaluation, except for low-grade heart block and ocular problems. General anesthesia was conducted with a minimum dose of thiopental sodium and sevoflurane under close monitoring, and a laryngeal mask was inserted without muscle relaxation. The surgery was uneventful; however, a careful approach was required during anesthesia because life-threatening complications may occur in patients with KSS.

Síndrome de Kearns-Sayre: relato de dois casos / Kearns-Sayre syndrome: two case reports

Descrevem-se dois casos em que os pacientes tinham como queixa principal a baixa da acuidade visual progressiva em evolução de quatro anos e oito meses, respectivamente. O quadro clínico de oftalmoplegia externa, com alterações fundoscópicas demonstrando atrofia da retina, epitélio pigmentar e coriocapilar, levou ao diagnóstico clínico de síndrome de Kearns-Sayre. A investigação etiológica do quadro oftalmológico é fundamental, pois na maioria das vezes está associado a condições sistêmicas graves que necessitam de acompanhamento e tratamento adequados.

Two cases in which patients had progressive loss of visual acuity in four years and eight months respectively are described. Clinical examination revealed fundoscopic alterations of the retina, pigment epithelium and choriocapillaris showing marked atrophy. The clinical picture resembles Kearns-Sayre syndrome. Etiological investigation is fundamental, because most of time this condition is associated with more serious systemic complications which need specific care.

Clinical and Laboratory Features of Children with Mitochondrial Respiratory Chain Enzyme Complexes Defect and Neurological Abnormalities: A case report

Mitochondrial cytopathies represent a heterogeneous group of multisystem disorder that preferentially affects the muscle and nervous systems. Mitochondrial respiratory chain enzyme complexes (MRC) defect can be the cause of many unexplained neurological disorders including epilepsy, cerebral palsy, delayed development and hypotonia. We retrospectively reviewed clinical and laboratory features of 16 patients who showed defects in MRC activity, confirmed by biochemical assay from spectrophotometry in muscles to characterize clinical and laboratory features for MRC defects and provide more precise diagnosis and effective treatments. In the patients with uncontrolled seizure activity, developmental regression, characteristic features of bilateral symmetric high signal intensity at deep nucleus and/or white matter in T2WI, the mitochondrial cytopathies should be added to the list of differential diagnoses. And lactate elevation in magnetic resonance spectroscopy (MRS) can be useful in the diagnosis of mitochondrial cytopathies.

Síndrome de Kearns-Sayre / Kearns-Sayre syndrome

A síndrome de Kearns-Sayre é uma patologia rara, que acarreta piora da qualidade de vida; caracteriza-se por oftalmoplegia externa progressiva, fraqueza muscular e distúrbios na condução cardíaca. A entidade integra um grupo de desordens do metabolismo mitocondrial, denominadas miopatias mitocondriais ou citopatias mitocondriais.

Kearns-Sayres syndrome is a rare pathology which leads to a worse quality of life of the individual; it is characterized by progressive external ophthalmoplegia, muscular weakness, and cardiac conduction defects. The disease belongs to a group of mitochondrial metabolic disorders, named mitochondrial myopathies of mitochondrial cytopathies.

A Case of the Hypercalcemia Induced by the Coenzyme Q10 and Alphacalcidol Treatment in a Patient with Kearns-Sayre Syndrome and Hypoparathyroidism / 대한소아내분비학회지

Kearns-Sayre Syndrome (KSS) is rare mitochondrial disorder characterized by chronic progressive external ophthalmoplegia, atypical retinal pigmentation and complete heart block. It is occasionally combined endocrinologic symptoms such as hypoparathyroidism, short stature, diabetes mellitus and hypothyroidism. We reported the effect of Coenzyme Q10 on total serum calcium concentration in 17 years old girl with KSS and hypoparathyroidism. The patients was treated with alfacalcidol (1alpha-OHD3), Coenzyme Q10 and oral calcium agent. Total serum calcium concentration had even remained within normal range and hypercalcemia was developed suddenly after treatment of combination of Coenzyme Q10 and alfacalcidol (1alpha-OHD3). After stop of all medication, her total calcium concentration was decreased to 7.6 mg/dL and remained in normal range with oral calcium (2 g/day) and Coenzyme Q10 (150 mcg/day) daily. The action of Coenzyme Q10 is not clearly defined but, we could explain Coenzyme Q10 activates the capacity of the patient to produce the active form of Vitamin D, 1alpha-OHD3.