Lower-back pain and weight loss in a 75-year-old man / Douleurs lombaires et perte de poids chez un homme de 75 ans

A 75-year-old men is adressed in rheumatology for lower back pain, asthenia, and recent weight loss. Myeloma is suspected. Anemia, hyperproteinemia as well as a monoclonal IgG kappa with serum protein immunofixation are discovered. The diagnosis is confirmed by the myelogram with 14% of medullar plasmocytes. Osteolytic lesions are also found on the scanner.

Un homme de 75 ans a consulté en rhumatologie pour des douleurs lombaires, une asthénie et une perte de poids d'apparition récente. Un myélome est suspecté. Une anémie, une hyperprotidémie ainsi qu'une IgG kappa monoclonale à l'immunofixation des protéines sériques sont retrouvés. Le diagnostic est confirmé par le myélogramme qui décompte 14 % de plasmocytes. Des lésions ostéolytiques sont également mises en évidence au scanner.

[Limb-Girdle Muscular Dystrophy type R9 linked to the FKRP gene: state of the art and therapeutic perspectives]. / La dystrophie musculaire des ceintures de type R9 liée au gène FKRP - État des lieux et perspectives thérapeutiques.

Mutations in the FKRP gene encoding the fukutin-related protein (FKRP) cause a wide spectrum of myopathies, ranging from severe forms of congenital muscular dystrophies associated with structural abnormalities of the central nervous system, to exertional myalgia or asymptomatic hyperCKemia, and to a form of limb girdle muscular dystrophy, LGMD-R9, (ex-LGMD-2I). LGMD-R9 is characterized by a proximal girdle deficit predominantly in the lower limbs to start with, with respiratory and cardiac damage that may affect the vital prognosis. Serum CK levels are markedly elevated and, on muscle biopsy, is detected a dystrophic formula associated with a reduction in the glycosylation of α-dystroglycan by immunostains and immunoblotting. Muscle MRI typically shows damage to proximal muscles (iliopsoas, adductors, gluteus maximus, quadriceps) with relative preservation of the muscles of the anterior compartment of the thighs (gracilis and sartorius). Genetic analysis, by specific sequencing of the FKRP gene or of a panel grouping together all the genes involved in the glycosylation of α-dystroglycan, or a larger panel of genes, generally confirms the diagnosis, the most frequent mutation being the missense p.(Leu276Ile). Currently, treatment of LGMD-R9 is symptomatic, requiring a multidisciplinary approach. A prospective study of the natural history of the disease is currently underway in Europe (GNT-015-FKRP). New therapeutic approaches are envisaged, such as gene therapy mediated by vectors derived from the adeno-associated virus (AAV). This is effective in animal models, allowing correction of defects in the glycosylation of alpha-dystroglycan and an increase in its binding capacity to the extracellular matrix. At the same time, preclinical studies have shown, in an animal model, the efficacy of ribitol, an alcohol pentose found in natural compounds, which has led to a phase I trial whose clinical development is underway.

TITLE: La dystrophie musculaire des ceintures de type R9 liée au gène FKRP - État des lieux et perspectives thérapeutiques. ABSTRACT: Les mutations du gène FKRP codant la fukutin-related protein (FKRP) sont à l'origine d'un large éventail de myopathies allant de formes sévères de dystrophies musculaires congénitales associées à des anomalies structurales du système nerveux central, jusqu'à des tableaux de myalgies à l'effort ou d'hyperCKémie asymptomatique, en passant par une forme de dystrophie musculaire des ceintures, la LGMD-R9 (ex-LGMD-2I), pour limb girdle muscular dystrophy récessive de type R9. La LGMD-R9 se caractérise par un déficit proximal des ceintures prédominant initialement aux membres inférieurs, avec une atteinte respiratoire et cardiaque pouvant conditionner le pronostic vital. Le taux sérique de CPK est nettement élevé et s'accompagne, sur la biopsie musculaire, d'une formule dystrophique associée à une réduction de la glycosylation de l'α-dystroglycane visible en immunomarquage et par immunoblot. L'IRM musculaire montre typiquement une atteinte des muscles proximaux (iliopsoas, adducteurs, grands fessiers, quadriceps) avec une relative préservation des muscles de la loge antérieure des cuisses (gracilis et sartorius). L'analyse génétique, par séquençage spécifique du gène FKRP ou d'un panel regroupant l'ensemble des gènes impliqués dans la glycosylation de l'α-dystroglycane, ou bien d'un panel plus large de gènes, confirme généralement le diagnostic, la mutation la plus fréquente étant le faux-sens p.(Leu276Ile). Actuellement, le traitement de la LGMD-R9 est symptomatique, requérant une approche pluridisciplinaire. Une étude prospective d'histoire naturelle de la maladie est en cours en Europe (GNT-015-FKRP). Des approches thérapeutiques inédites sont envisagées, telles que la thérapie génique médiée par des vecteurs dérivés du virus adéno-associé (AAV). Celle-ci est efficace dans les modèles animaux, permettant une correction des défauts de glycosylation de l'a-dystroglycane et une augmentation de sa capacité de liaison à la matrice extracellulaire. En parallèle, des études précliniques ont montré, dans un modèle animal, l'efficacité du ribitol, un pentose alcool retrouvé dans des composés naturels, ce qui a conduit à un essai de phase I dont le développement clinique est en cours.

Muscular, Ocular and Brain Involvement Associated with a De Novo 11q13.2q14.1 Duplication: Contribution to the Differential Diagnosis of Muscle-Eye-Brain Congenital Muscular Dystrophy.

Muscular weakness and hypotonia may be associated with multisystem involvement giving rise to complex phenotypes, many of which are uncharacterized. We report a patient presenting with congenital hypotonia and severe ocular and brain abnormalities, evoking a Muscle Eye Brain disease (MEB). She had global muscular weakness, hypotonia and amyotrophy, joint hyperlaxity, kyphoscoliosis, respiratory insufficiency, dysmorphic features and severe intellectual disability. Brain MRI showed cortical atrophy and hypoplasia of the corpus callosum. Normal CK levels, non-progressive course and absence of dystrophic features or α-dystroglycan abnormalities on the muscle biopsy were not typical of MEB. CGH array identified a large de novo duplication in chromosome 11, including regions partially duplicated in three other patients with common clinical features. This report adds to the differential diagnosis of complex phenotypes characterized by muscular, ocular and CNS involvement and highlights the potential contribution of still unrecognized chromosomal abnormalities to these phenotypes.

A National French consensus on gene lists for the diagnosis of myopathies using next-generation sequencing.

Next-generation sequencing (NGS) gene-panel-based analyses constitute diagnosis strategies which are adapted to the genetic heterogeneity within the field of myopathies, including more than 200 implicated genes to date. Nonetheless, important inter-laboratory diversity of gene panels exists at national and international levels, complicating the exchange of data and the visibility of the diagnostic offers available for referring neurologists. To address this issue, we here describe the initiative of the genetic diagnosis section of the French National Network for Rare Neuromuscular Diseases (Filière Nationale des Maladies Rares Neuromusculaires, FILNEMUS), which led to set up a consensual nationwide diagnostic strategy among the nine French genetic diagnosis laboratories using NGS for myopathies. The strategy is based on the determination of 13 clinical and/or histological entry-diagnosis groups, and consists for each group either in a successive NGS analysis of a "core gene list" followed in case of a negative result by the analysis of an "exhaustive gene list", or in the NGS analysis of a "unique exhaustive gene list".

Limb girdle muscular dystrophy due to mutations in POMT2.

BACKGROUND: Mutations in the gene coding for protein O-mannosyl-transferase 2 (POMT2) are known to cause severe congenital muscular dystrophy, and recently, mutations in POMT2 have also been linked to a milder limb-girdle muscular dystrophy (LGMD) phenotype, named LGMD type 2N (LGMD2N). Only four cases have been reported so far.ClinicalTrials.gov ID: NCT02759302 METHODS: We report 12 new cases of LGMD2N, aged 18-63 years. Muscle involvement was assessed by MRI, muscle strength testing and muscle biopsy analysis. Other clinical features were also recorded. RESULTS: Presenting symptoms were difficulties in walking, pain during exercise, delayed motor milestones and learning disabilities at school. All had some degree of cognitive impairment. Brain MRIs were abnormal in 3 of 10 patients, showing ventricular enlargement in one, periventricular hyperintensities in another and frontal atrophy of the left hemisphere in a third patient. Most affected muscle groups were hip and knee flexors and extensors on strength testing. On MRI, most affected muscles were hamstrings followed by paraspinal and gluteal muscles. The 12 patients in our cohort carried 11 alleles with known mutations, whereas 11 novel mutations accounted for the remaining 13 alleles. CONCLUSION: We describe the first cohort of patients with LGMD2N and show that unlike other LGMD types, all patients had cognitive impairment. Primary muscle involvement was found in hamstring, paraspinal and gluteal muscles on MRI, which correlated well with reduced muscle strength in hip and knee flexors and extensors. The study expands the mutational spectrum for LGMD2N, with the description of 11 novel POMT2 mutations in the association with LGMD2N. CLINICAL TRIAL REGISTRATION: NCT02759302.

ISPD produces CDP-ribitol used by FKTN and FKRP to transfer ribitol phosphate onto α-dystroglycan.

Mutations in genes required for the glycosylation of α-dystroglycan lead to muscle and brain diseases known as dystroglycanopathies. However, the precise structure and biogenesis of the assembled glycan are not completely understood. Here we report that three enzymes mutated in dystroglycanopathies can collaborate to attach ribitol phosphate onto α-dystroglycan. Specifically, we demonstrate that isoprenoid synthase domain-containing protein (ISPD) synthesizes CDP-ribitol, present in muscle, and that both recombinant fukutin (FKTN) and fukutin-related protein (FKRP) can transfer a ribitol phosphate group from CDP-ribitol to α-dystroglycan. We also show that ISPD and FKTN are essential for the incorporation of ribitol into α-dystroglycan in HEK293 cells. Glycosylation of α-dystroglycan in fibroblasts from patients with hypomorphic ISPD mutations is reduced. We observe that in some cases glycosylation can be partially restored by addition of ribitol to the culture medium, suggesting that dietary supplementation with ribitol should be evaluated as a therapy for patients with ISPD mutations.

Dystroglycanopathies: About Numerous Genes Involved in Glycosylation of One Single Glycoprotein.

Dystroglycanopathies are neuromuscular disorders due to abnormal glycosylation of dystroglycan which is a cell-surface glycoprotein that acts as a receptor for extracellular matrix proteins containing laminin-G domains. The reduced ability of abnormally glycosylated α-DG to bind laminin is associated with abnormal neuronal migration and muscular dystrophy. Clinical manifestations are extremely variable, and include a wide spectrum of phenotypic severity: some mutations are associated with adult-onset Limb-girdle muscular dystrophy and other mutations with a congenital onset, determining the more complex disorder Congenital Muscular Dystrophy which includes severe structural brain and eye anomalies such as Muscle-Eye-Brain Disease, Walker-Warburg Syndrome, and Fukuyama Congenital Muscular Dystrophy. So far, mutations in eighteen different genes have been identified in patients with dystroglycanopathies, all of them demonstrating autosomal recessive inheritance. Most genes code for glycosyltransferases (POMT1, POMT2, POMGNT1, LARGE, GTDC2, B4GAT1, B3GALNT2) although a minority does not (DPM1, DPM2, DPM3, DOLK, POMK, GMPPB). Others genes code for proteins of unknown function in the α-dystroglycan glycosylation (FKTN, FKRP, ISPD, and TMEM5) or α-dystroglycan itself, DAG1. The biochemical picture becomes a little bit more complete, but also more complex, with each new identified gene. In the majority of cases the identity of the defective gene cannot be predicted from the clinical phenotype. Considering the number of causative genes in dystroglycanopathies, targeted sequencing comprising genes of all glycosylation, whatever the type, would appear at present to be the best way of tackling molecular diagnosis.

Identification of mutations in TMEM5 and ISPD as a cause of severe cobblestone lissencephaly.

Cobblestone lissencephaly is a peculiar brain malformation with characteristic radiological anomalies. It is defined as cortical dysplasia that results when neuroglial overmigration into the arachnoid space forms an extracortical layer that produces agyria and/or a "cobblestone" brain surface and ventricular enlargement. Cobblestone lissencephaly is pathognomonic of a continuum of autosomal-recessive diseases characterized by cerebral, ocular, and muscular deficits. These include Walker-Warburg syndrome, muscle-eye-brain disease, and Fukuyama muscular dystrophy. Mutations in POMT1, POMT2, POMGNT1, LARGE, FKTN, and FKRP identified these diseases as alpha-dystroglycanopathies. Our exhaustive screening of these six genes, in a cohort of 90 fetal cases, led to the identification of a mutation in only 53% of the families, suggesting that other genes might also be involved. We therefore decided to perform a genome-wide study in two multiplex families. This allowed us to identify two additional genes: TMEM5 and ISPD. Because TMEM has a glycosyltransferase domain and ISPD has an isoprenoid synthase domain characteristic of nucleotide diP-sugar transferases, these two proteins are thought to be involved in the glycosylation of dystroglycan. Further screening of 40 families with cobblestone lissencephaly identified nonsense and frameshift mutations in another four unrelated cases for each gene, increasing the mutational rate to 64% in our cohort. All these cases displayed a severe phenotype of cobblestone lissencephaly A. TMEM5 mutations were frequently associated with gonadal dysgenesis and neural tube defects, and ISPD mutations were frequently associated with brain vascular anomalies.