Danon Disease: Entire LAMP2 Gene Deletion with Unusual Clinical Presentation-Case Report and Review of the Literature.

Danon disease is a rare x-linked dominant multisystemic disorder with a clinical triad of severe cardiomyopathy, skeletal myopathy, and intellectual disability. It is caused by defects in the lysosome-associated membrane protein-2 (LAMP2) gene. Numerous different mutations in the LAMP2 protein have been described. Danon disease is typically lethal by the mid-twenties in male patients due to cardiomyopathy and heart failure. Female patients usually present with milder and variable symptoms. This report describes a 42-year-old father and his 3-year-old daughter presenting with mild manifestations of the disease. The father has normal intellectual development and normal physical activity. At the age of 13, he was diagnosed with mild ventricular pre-excitation known as Wolf-Parkinson-White syndrome (WPWs), very mild and mostly asymptomatic cardiomyopathy and left ventricular hypertrophy, and at about the age of 25 presented with visual impairment due to cone-rod dystrophy. His daughter showed normal development and very mild asymptomatic electrocardiographic WPWs abnormalities with left mild ventricular hypertrophy. Genetic testing revealed an Xq24 microdeletion encompassing the entire LAMP2 gene. Relevant literature was reviewed as a reference for the etiology, diagnosis, treatment and case management.

Exercise and immobilization in aging animals: the involvement of oxidative stress and NF-kappaB activation.

In the early 1980s, the concept of threshold of age in exercise and aging was proposed. In several studies it was shown that subjecting young animals to short periods of moderate to intense exercise improved the biochemical and morphological status of their skeletal muscles. This was not the case for old animals subjected to the same exercise regimens. Thus, by measuring several muscle energy-providing enzymes as well as antioxidant enzymes it was demonstrated that their levels and activities increased in young animals postexercise, while in old animals reduced activity of these enzymes was found on completion of the training. However, old animals that started training in young and middle age were still capable of improving their muscle condition as a result of exercise, as long as the onset of training was below a specific age threshold. In the following years, it was shown that intense physical exercise in young humans and animals is accompanied by elevation of oxidative stress parameters in muscles and other organs. Specifically, strenuous training of animals led to increased protein oxidation as measured by protein carbonyl accumulation in muscles, which could be attenuated by the administration of vitamin E. Nuclear factor kappaB (NF-kappaB) is a redox-sensitive transcription factor responsive to closely related reactive oxygen species (ROS) and reactive nitrogen species (RNS) redox cascades. Its involvement in exercise and immobilization has been demonstrated in several studies, indicating that these conditions may lead to inflammatory responses and to oxidative damage to tissues. Indeed, recent studies have revealed that NF-kappaB is involved in inflammatory responses that may result in muscle protein degradation. Additional studies have also demonstrated that the pattern and type of the NF-kappaB activation pathway vary between muscles of young and old animals subjected to limb immobilization for several weeks. This indicates that NF-kappaB may play a crucial role in the regulation of both inflammatory processes and protein turnover and degradation in muscles of old animals. Thus, the modulation of NF-kappaB activity in muscles of old animals by specific inhibitors may provide a means to retard muscle damage and protein degradation under conditions of immobilization.

Reactive nitrogen species induce nuclear factor-kappaB-mediated protein degradation in skeletal muscle cells.

Recently, a role for NF-kappaB in upregulation of proteolytic systems and protein degradation has emerged. Reactive nitrogen species (RNS) have been demonstrated to induce NF-kappaB activation. The aim of this study was to investigate whether RNS caused increased proteolysis in skeletal muscle cells, and whether this process was mediated through the activation of NF-kappaB. Fully differentiated L6 myotubes were treated with NO donor SNAP, peroxynitrite donor SIN-1, and authentic peroxynitrite, in a time-dependent manner. NF-kappaB activation, the activation of the ubiquitin-proteasome pathway and matrix metalloproteinases, and the levels of muscle-specific proteins (myosin heavy chain and telethonin) were investigated under the conditions of nitrosative stress. RNS donors caused NF-kappaB activation and increased activation of proteolytic systems, as well as the degradation of muscle-specific proteins. Antioxidant treatment, tyrosine nitration inhibition, and NF-kappaB molecular inhibition were proven effective in downregulation of NF-kappaB activation and slowing down the degradation of muscle-specific proteins. Peroxynitrite, but not NO, causes proteolytic system activation and the degradation of muscle-specific proteins in cultured myotubes, mediated through NF-kappaB. NF-kappaB inhibition by antioxidants, tyrosine nitration, and molecular inhibitors may be beneficial for decreasing the extent of muscle damage induced by RNS.

Peroxynitrite induces an alternative NF-kappaB activation pathway in L8 rat myoblasts.

The role of peroxynitrite in NF-kappaB activation remains controversial. This study investigated NF-kappaB activation by peroxynitrite in skeletal myocytes. Myocytes were treated with NO and peroxynitrite donors. Both NO and peroxynitrite caused NF-kappaB activation (measured by p65 nuclear translocation and luciferase expression). NO donor-induced NF-kappaB activation was transient, dependent on I-kappaB alpha degradation, and was decreased in the presence of I-kappaB alpha super-repressor. Conversely, peroxynitrite donors induced NF-kappaB activation that was dependent on tyrosine nitration of I-kappaB alpha, but independent of its serine phosphorylation and degradation. This activation did not decrease in the presence of I-kappaB alpha super-repressor. Prolonged exposure to peroxynitrite resulted in nontransient NF-kappaB activation and high iNOS expression. Proteasome inhibitor MG-132 did not diminish SIN-1-induced NF-kappaB activation. Tyrosine nitration inhibitor EGCG re-established transient NF-kappaB activation with I-kappaB alpha degradation after SIN-1 treatment. EGCG, but not MG-132 decreased SIN-1- dependent iNOS expression. Peroxynitrite activates NF-kappaB in skeletal myocytes through an alternative mechanism, in which I-kappaB alpha is nitrated on tyrosine and dissociated from NF-kappaB, thus enabling its nontransient activation. This resulted in prolonged iNOS expression. Hence, peroxynitrite may exacerbate inflammatory responses mediated by NF-kappaB.

The role of NF-kappaB in protein breakdown in immobilization, aging, and exercise: from basic processes to promotion of health.

Between the ages of 20 and 80 years, humans lose about 20-30% of their skeletal muscle weight. This phenomenon has been termed sarcopenia of old age and is directly involved in the well-being of the aged. With aging, people tend to be less mobile and are frequently bedridden, which exacerbates the muscle weight loss. The molecular mechanisms responsible for the muscle protein breakdown during immobilization in aging have been studied in our laboratory in a model of 24-month-old Wistar rats, immobilized for 4 weeks. Subsequently we investigated the activation of the intracellular and extracellular proteolytic systems in the immobilized muscles. A similar group of young (6-month-old) rats was examined and compared to the older rats. The involvement of NF-kappaB transcription factor in muscle atrophy was assessed in immobilized muscles of young and old animals. There were marked differences in the kinetics and the pattern of NF-kappaB activation in young versus old muscles. It seems that in both young and old animals in the early stages of limb immobilization, an alternative pathway of NF-kappaB activation can be observed. However, in late stages of immobilization, the canonic pathway of NF-kappaB activation (p65/p50 complex with I-kappaB alpha degradation) is predominant. Interestingly, the canonic activation pathway is more prominent in muscles from old animals compared to young ones. The activation of NF-kappaB has been observed also in muscles subjected to acute and intense exercise, implying that inflammatory processes may take place under the conditions of intense exercise. This may cause muscle damage and protein breakdown. Therefore, using NF-kappaB pathway inhibitors may prove beneficial in attenuating NF-kappaB-associated muscle damage in both disuse atrophy and strenuous exercise.

The effect of hindlimb immobilization on acid phosphatase, metalloproteinases and nuclear factor-kappaB in muscles of young and old rats.

Age-associated muscle wasting (sarcopenia of old age) is a major problem in elderly people, however, the mechanisms of muscle proteolysis in aging remain obscure and enigmatic. Possible reasons for loss of skeletal muscle mass with aging may be attributed to multiple and complex proteolytic systems. The purpose of the present study was to explore the kinetics of activation of extracellular hydrolytic and proteolytic systems in muscles of hindlimbs immobilized by external fixation of 24-month-old female Wistar rats, in comparison with those of 6-month-old rats. Results show that elevated acid phosphatase activities (lysosomal hydrolytic enzyme activated mainly in macrophages) in immobilized limb muscles of young animals, differ from old animals. In young rats external fixation resulted in significantly elevated acid phosphatase activities (50-55%; p<0.05) after 4 weeks of immobilization, whereas in old animals similar increases were observed already during the first and second weeks of immobilization. The extracellular proteolytic enzymes, matrix metalloproteinases (MMP-2 and -9), were also differentially activated in old animals compared to young animals. In young animals, as shown in previous studies, both MMP-2 and -9 activities were elevated significantly in immobilized muscles. In this study of old animals, only MMP-2 activity was detected, with no significant elevation in the immobilized muscles of old animals. In addition, the levels of the transcription factor Nuclear Factor-kappaB (NF-kappaB) in nuclear extracts of old rat muscles, as detected by ELISA, showed a biphasic pattern after immobilization, suggesting that NF-kappaB could be activated by different processes in the atrophy process, at least in the old age. In conclusion, it seems that the kinetics of activation of extracellular hydrolytic and proteolytic systems differ in muscles of old animals compared to young animals.

Mechanisms in muscle atrophy in immobilization and aging.

The purpose of this report was to study the effects of four weeks of hindlimb immobilization on acid phosphatase activity of old rats in comparison with the profile obtained after similar treatment in young rats.

Expression of matrix metalloproteinases, inhibitor, and acid phosphatase in muscles of immobilized hindlimbs of rats.

External fixation procedures of limb immobilization provide excellent experimental models to study mechanisms involved in muscle disuse atrophy and recovery. Female Wistar rats (7-8 months old) had their right hindlimbs immobilized by an external fixation procedure for 5, 10, 21, and 30 days. Muscle mass of the gastrocnemius and quadriceps muscles was reduced by 41-46% in comparison with contralateral nonimmobilized legs. Acid phosphatase activities were significantly increased after 21 and 30 days of hindlimb immobilization. Histochemical staining for acid phosphatase activities increased in myofibers after the external fixation and also in macrophages in the adjacent extracellular matrix. Matrix metalloproteinase (MMP-2 and MMP-9) activities assessed by gel zymography and also a tissue inhibitor of metalloproteinases (TIMP-1) assessed by Western blot were elevated in the immobilized hindlimb muscles. Our study demonstrated that metalloproteinases are expressed relatively late after limb immobilization and appear to be responsible to a large degree for degradation of the extracellular matrix in experimental disuse atrophy.