Brain Advance Access originally published online on January 7, 2004
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Brain, Vol. 127, No. 2, 439-451, 2004
© 2004 Guarantors of Brain
doi: 10.1093/brain/awh052
Myofibrillar myopathy: clinical, morphological and genetic studies in 63 patients
Department of Neurology and Neuromuscular Research Laboratory, Mayo Clinic, Rochester, MN, USA
Correspondence to: Dr Duygu Selcen, Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA E-mail: Selcen.Duygu{at}mayo.edu
The term myofibrillar myopathy (MFM) was proposed in 1996 as a non-committal term for a pathological pattern of myofibrillar dissolution associated with accumulation of myofibrillar degradation products and ectopic expression of multiple proteins that include desmin, 
B-crystallin (BC), dystrophin and congophilic amyloid material. Subsequent studies revealed dominant mutations in desmin and BC in some MFM patients, and clinical differences between kinships. We here review the clinical, structural and genetic features of 63 unrelated patients diagnosed as having MFM at the Mayo Clinic between 1977 and 2003. The age of onset was 54 ± 16 years (mean ± SD). Weakness was both proximal and distal in 77% and proximal only in 13%. Cardiomyopathy was diagnosed in 16%. Electro myography revealed a myopathic pattern associated with abnormal electrical irritability; 13 patients had abnormal nerve conduction studies but four of these had long-standing diabetes. The abnormal muscle fibres are best identified in trichrome-stained sections as harbouring amorphous, granular or pleomorphic hyaline structures, and vacuoles containing membranous material. The hyaline structures are strongly congophilic. Semiquantitative analysis in each case indicates that among the abnormal fibres, an average of 90, 75, 75, 70 and 70% abnormally express myotilin, desmin, BC, dystrophin and ß-amyloid precursor protein, respectively. Therefore, immunostains for these proteins, and especially for myotilin, are useful adjuncts in the diagnosis of MFM. Electron microscopy shows progressive myofibrillar degeneration commencing at the Z-disk, accumulation of degraded filamentous material and entrapment of dislocated membranous organelles in autophagic vacuoles. In all patients, we searched for mutations in desmin and BC, as well as in telethonin, a Z-disk-associated protein, or in syncoilin, which together with plectin links desmin to the Z-disk. Two of the 63 patients carry truncation mutations in the C-terminal domain of BC, four carry missense mutations in the head or tail region of desmin, and none carries a mutation in syncoilin or telethonin. Thus, MFM is morphologically distinct but genetically heterogeneous. Further advances in defining the molecular causes of MFM will probably come from linkage studies of informative kinships or from systematic search for mutations in proteins participating in the intricate network supporting the Z-disk.
Key Words:
myofibrillar myopathy; Z-disk; desmin; B-crystallin; mutation analysis
Abbreviations:
BC= B-crystallin; Aß = ß-amyloid protein; ßAPP = ß-amyloid precursor protein; CDC = cell division cycle; KPI = Kunitz protease inhibitor; LGMD = limb-girdle muscular dystrophy; MFM = myofibrillar myopathy; MUP = motor unit potential; NCAM = neural cell adhesion molecule.
Received August 19, 2003. Revised October 10, 2003. Accepted October 13, 2003.
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