[Psychiatric disturbances in five patients with MELAS syndrome]. / Zaburzenia psychiczne u pieciu pacjentów cierpiacych na zespól MELAS.

OBJECTIVES: Mitochondrial disorders of energetic metabolism (MD) represent a heterogeneous group of diseases manifesting at any age with a broad spectrum of clinical symptoms, including psychiatric disorders. METHODS: The aim of the study was to characterize psychiatric symptoms and diagnoses in five patients with MELAS syndrome between the ages of 17 and 53 years. RESULTS: Four of MELAS patients them harbored the prevalent mitochondrial DNA (mtDNA) mutation 3243A>G, and one patient had the mtDNA mutation 12706T>C. Three patients had positive family histories for MELAS syndrome. In one patient, depression was diagnosedas the first symptom ofMELAS syndrome. Depression also preceded a stroke-like episode in one patient. Four patients had disturbed cognitive functions, confusional states occurred in three patients. One patient manifested psychotic (schizophrenia-like) symptoms. CONCLUSION: Mitochondrial disorders deserve consideration as part of the differential diagnosis, especially, if there is suspected involvement of other organ groups or positive family history of MD.

The psychiatric manifestations of mitochondrial disorders: a case and review of the literature.

OBJECTIVE: Mitochondrial disorders are caused by gene mutations in mitochondrial or nuclear DNA and affect energy-dependent organs such as the brain. Patients with psychiatric illness, particularly those with medical comorbidities, may have primary mitochondrial disorders. To date, this issue has received little attention in the literature, and mitochondrial disorders are likely underdiagnosed in psychiatric patients. DATA SOURCES: This article describes a patient who presented with borderline personality disorder and treatment-resistant depression and was ultimately diagnosed with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) 3271. We also searched the literature for all case reports of patients with mitochondrial disorders who initially present with prominent psychiatric symptoms by using MEDLINE (from 1948-February 2011), Embase (from 1980-February 2011), PsycINFO (from 1806-February 2011), and the search terms mitochondrial disorder, mitochondria, psychiatry, mental disorders, major depression, anxiety, schizophrenia, and psychosis. STUDY SELECTION: Fifty cases of mitochondrial disorders with prominent psychiatric symptomatology were identified. DATA EXTRACTION: Information about the psychiatric presentation of the cases was extracted. This information was combined with our case, the most common psychiatric manifestations of mitochondrial disorders were identified, and the important diagnostic and treatment implications for patients with psychiatric illness were reviewed. RESULTS: The most common psychiatric presentations in the cases of mitochondrial disorders included mood disorder, cognitive deterioration, psychosis, and anxiety. The most common diagnosis (52% of cases) was a MELAS mutation. Other genetic mitochondrial diagnoses included polymerase gamma mutations, Kearns-Sayre syndrome, mitochondrial DNA deletions, point mutations, twinkle mutations, and novel mutations. CONCLUSIONS: Patients with mitochondrial disorders can present with primary psychiatric symptomatology, including mood disorder, cognitive impairment, psychosis, and anxiety. Psychiatrists need to be aware of the clinical features that are indicative of a mitochondrial disorder, investigate patients with suggestive presentations, and be knowledgeable about the treatment implications of the diagnosis.

Decreased hippocampal expression of calbindin D28K and cognitive impairment in MELAS.

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a maternally inherited mitochondrial syndrome characterized by seizures, migrainous headaches, lactic acidosis, vomiting, and recurrent stroke-like episodes. Patients often suffer from cognitive dysfunction of unclear pathogenesis. In this study, we explored a possible link between cognitive dysfunction and hippocampal expression of calbindin D(28KD) (CB), a high affinity calcium-binding protein, in four MELAS patients, using post mortem hippocampal tissues. We found significantly reduced CB levels in all patients by immunohistochemistry, Western blot, and quantitative real-time PCR. Reduction in CB expression has been associated with aging and with neurodegenerative disorders, including Alzheimer's disease. We postulate that the reduced CB expression may play a role in the cognitive abnormalities associated with MELAS.

Obsessive-compulsive disorder with mitochondrial disease.

BACKGROUND: Mitochondrial diseases are among the most common genetic disorders, and they have been associated with several psychiatric syndromes. METHOD: The authors present two cases of obsessive-compulsive disorder (OCD) occurring in patients with MELAS (the A3243G mutation). RESULTS: Their clinical course and response to standard OCD treatment strategies was poor. DISCUSSION: Possible mechanisms for OCD symptoms are suggested by animal models and neuropathological findings. It remains unclear whether different types of mitochondrial disorders are associated with particular neuropsychiatric symptoms. Psychiatric symptoms may predate the diagnosis of mitochondrial disorder; thus, psychiatrists should consider mitochondrial disorders in the presence of common physical signs that are typically associated with these disorders.

The neuropsychologic deficits of MELAS: evidence of global impairment.

OBJECTIVE: To examine the neuropsychologic profile of MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes) and relate it to neuropathologic findings. BACKGROUND: MELAS is one of over 40 mitochondrial disorders. Symptoms include seizures, strokelike episodes, headaches, memory impairment, hemianopsia, hearing loss, short stature, diffuse limb weakness, exercise intolerance, nausea, and vomiting. Age of onset ranges from 2 to 40 years. A hallmark of MELAS is normal development until the first symptoms appear. METHOD: Because information regarding the neuropsychologic functioning of these individuals is sparse, we report findings from detailed neuropsychologic evaluations for a 13-year-old white male and a 33-year-old African-American male with MELAS. RESULTS: Results revealed global patterns of deterioration in executive function, attention, language, memory, visuospatial, and motor functioning. In both patients, brain scans revealed posterior pathology in the absence of frontal pathology. CONCLUSIONS: We compared our findings with other documented cases and concluded that MELAS is characterized by a pattern of global deterioration. This pattern differs from that observed in other mitochondrial disorders. The absence of identifiable frontal lobe pathology despite the presence of deficits in executive functioning may be related to the distribution patterns of deficient mitochondria and neuronal projection patterns.

[A case with late-onset MELAS with hallucination and delusion].

We report a 53-year-old male patient with late onset mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes(MELAS) with hallucination and delusion. The patient manifested various neurological symptoms including perceptive deafness, muscle weakness of limbs with loss of consciousness, sensory abnormalities in hands, feet and a face, abnormal sense of taste, tremor, palsy of upward eye movement and weak deep tendon reflexes prior to the psychotic episode. He was diagnosed as MELAS, because of high serum lactic acid and pyruvic acid, and the point mutation in the mitochondrial DNA 3243. SPECT imaging showed decreased perfusion in occipital cortex and thalamus. These SPECT changes improved after disappearing visual hallucination. Hallucination might be caused by delirium due to stroke-like episode. Dysfunction in the occipital cortex and thalamus might be involved with this perfusion change.

MELAS: a neuropsychological and radiological follow-up study. Mitochondrial encephalomyopathy, lactic acidosis and stroke.

We report on a patient with long standing, full-blown mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS). In contrast to earlier publications, detailed neuropsychological assessment revealed no dementia but a pattern of distinct cognitive deficits with marked impairment of visuo-constructive and executive functions. Focal lesions and progressing atrophy mainly of the basal ganglia and the temporo-parieto-occipital area with preservation of hippocampal and entorhinal structures were present. Furthermore, a 4-year follow-up assessment revealed an increasing deterioration of distinct cognitive functions, including phasic alertness, tactile functions and the discrimination of tone pitch and rhythm. This may be because of chronic regional metabolic disturbances, as there was no further stroke-like episode in that period of time.

[Pathomechanism and clinical presentation of neurobehavioral disturbances in a patient with MELAS syndrome]. / Patomechanizm i obraz kliniczny zaburzen neurobehawioralnych u pacjentki z zespolem MELAS.

The authors present the results of a longitudinal study of the neurobehavioral disturbances seen in K.S., a 22-year-old female patient with a mitochondrial cytopathy (MELAS) caused by the novel mutation C8293T. K.S. became ill in 1994 at the age of 16. She was referred for diagnosis to several different clinics. Four years after onset, the clinical diagnosis was established in the Department of Medical Rehabilitation at the Cracow Rehabilitation Center; the diagnosis was not confirmed until six years after onset, following the discovery of the mutation in the patient's mtDNA at Columbia University. Since 1996 the patient has presented with progressive dementia and periodic stroke-like episodes that produced fluctuating neurological symptoms. The essential pathomechanism of the neurobehavioral disturbances consists in the fragmentation of complex cerebral processes into their constituent elements; individual functions are frequently correctly executed on a lower level of cerebral organization, but the patient is unable to combine them into a sensible whole. The authors discuss the theoretical and clinical significance of the results presented here.

Mitochondrial dysfunction in bipolar disorder.

Mitochondrial dysfunction is implicated in bipolar disorder based on the following lines of evidence: 1) Abnormal brain energy metabolism measured by 31P-magnetic resonance spectroscopy, that is, decreased intracellular pH, decreased phosphocreatine (PCr), and enhanced response of PCr to photic stimulation. 2) Possible role of maternal inheritance in the transmission of bipolar disorder. 3) Increased levels of the 4977-bp deletion in mitochondrial DNA (mtDNA) in autopsied brains. 4) Comorbidity of affective disorders in certain types of mitochondrial disorders, such as autosomal inherited chronic progressive external ophthalmoplegia and mitochondrial diabetes mellitus with the 3243 mutation. Based on these findings, we searched for mtDNA mutations/ polymorphisms associated with bipolar disorder and found that 5178C and 10398A polymorphisms in mtDNA were risk factors for bipolar disorder. The 5178C genotype was associated with lower brain intracellular pH. mtDNA variations may play a part in the pathophysiology of bipolar disorder through alteration of intracellular calcium signaling systems. The mitochondrial dysfunction hypothesis, which comprehensively accounts for the pathophysiology of bipolar disorder, is proposed.

Effects of dichloroacetate in three patients with MELAS.

We present the clinical and laboratory effects of dichloroacetate (DCA) in three children with mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes (MELAS) who had not responded to other medications. Administration of DCA lowered the elevated levels of lactate and pyruvate in the serum and CSF. DCA ameliorated abdominal pain, headache, and strokelike episodes, and improved cognitive function and fatigability in the three patients during the study period. Some transient liver dysfunction, hypocalcemia, and peripheral neuropathy were observed. The use of DCA in MELAS merits further study.

Mitochondrial DNA mutations at nucleotide positions 3243 and 3271 in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes: a comparative study.

Of 50 patients with the clinical characteristics of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), 38 had a point mutation at nucleotide position (nt) 3243 in the tRNA(Leu(UUR)) region in mitochondrial DNA and 6 at nt 3271 in the same tRNA(Leu(UUR)) gene. Except for the later onset of the disease in the patients with the 3271 mutation, there were no clinical, biochemical and pathological differences between the two groups. Since the nt 3271 region is not located in the binding site for mitochondrial transcription termination (mTERM) factor, which has been proposed to be defective in the 3243 mutation, a functional defect in tRNA itself might be responsible for the enzyme defects in MELAS patients; however the mechanism by which the defective tRNA(Leu(UUR)) induces the stroke-like episodes remains to be clarified.