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Adult-Onset Mitochondrial Myopathy J Postgrad Med J: first published as 10.1136/pgmj.68.797.212 on 1 March 1992. Downloaded from Postgrad Med J (1992) 68, 212 - 215 © The Fellowship of Postgraduate Medicine, 1992 Adult-onset mitochondrial myopathy J. Fernandez-Sola, J. Casademont, J.M. Grau, F. Graus', F. Cardellach, E. Pedrol and A. Urbano-Marquez Muscle Research Group, Internal Medicine Service, and 'Department ofNeurology, Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain Summary: Mitochondrial diseases are polymorphic entities which may affect many organs and systems. Skeletal muscle involvement is frequent in the context of systemic mitochondrial disease, but adult-onset pure mitochondrial myopathy appears to be rare. We report 3 patients with progressive skeletal mitochondrial myopathy starting in adult age. In all cases, the proximal myopathy was the only clinical feature. Mitochondrial pathology was confirmed by evidence of ragged-red fibres in muscle histochemistry, an abnormal mitochondrial morphology in electron microscopy and by exclusion of other underlying diseases. No deletions of mitochondrial DNA were found. We emphasize the need to look for a mitochondrial disorder in some non-specific myopathies starting in adult life. Introduction Mitochondrial diseases consist ofvarious polymor- These patients usually have proximal muscleby copyright. phic pathological entities which usually involve weakness and myalgia. Muscle atrophy of the many organs and systems. They represent a wide affected areas is frequent. The whole clinical pic- clinical, pathological and biochemical spectrum.' ture is not specific and there is a wide differential Involvement ofskeletal and ocular muscles, central diagnosis including inflammatory, toxic, neoplas- and peripheral nervous system, liver, heart, blood tic, metabolic and endocrine myopathies. Skeletal vessels, retina and endocrine system has been muscle studies providing evidence of mitochon- described.2-4 Although they are considered diseases drial pathology give the diagnosis."3 of genetic origin,5 and maternal transmission has We describe 3 patients finally diagnosed as been suspected in some cases,6 no clear hereditary having adult-onset mitochondrial myopathy by http://pmj.bmj.com/ pattern has been established.7 Recently, mitochon- skeletal muscle biopsy in whom progressive proxi- drial DNA genomic deletions have been described mal myopathy was the only clinical feature. and correlated with biochemical defects.89 Muscle involvement in mitochondrial diseases is frequent,2 usually affecting patients under 20 years Case reports of age and clinically progressive. These patients usually have life-threatening multisystemic in- Case I volvement and a poor prognosis.'0 on September 29, 2021 by guest. Protected A different pattern of muscle involvement in A 67 year old woman with a family history of mitochondrial diseases has also been described, in long-standing bilateral ptosis in her mother and adult patients over 40 years of age who present a one brother had observed progressive ptosis for the chronic and slowly progressive myopathy as the past 10 years. Afterwards, she also noticed progres- only clinical feature of their mitochondrial sive limb weakness, dysphagia and occasional disorder" or an additional feature.'2 This is an diplopia. infrequent condition, clearly different from clas- Physical examination revealed bilateral ptosis sical mitochondrial myopathy in young patients. with vertical and horizontal restriction of ocular motility and proximal limb muscle atrophy. Muscle strength in the arms was IV-/V proximal and V/V distal (according to the MRC scale). Deep Correspondence: J. Fernandez-Sola, M.D. tendon reflexes were diminished. J. Fernandez-Sola is supported by a grant from CIRIT, Biochemical blood studies including creatine Generalitat of Cataluyna, Spain kinase, aspartate aminotransferase, lactic dehy- Accepted: 15 July 1991 drogenase, and aldolase were normal. There was no Postgrad Med J: first published as 10.1136/pgmj.68.797.212 on 1 March 1992. Downloaded from CLINICAL REPORTS 213 evidence of lactic acidosis. Electromyography revealed slight nerve motor conduction slowness and a clear myopathic pattern. The electro- myographical studies for myasthenia were negative and acetylcholine receptor antibodies were not detected. Endocrine studies including thyroid hor- mones and cortisol were also normal. Case 2 An 80 year old man without a remarkable family history developed myalgia and progressive weakness of his pelvic girdle muscles over 6 months. Physical examination and blood bio- chemical analysis were normal. He was clinically Figure 1 Muscle deltoid biopsy. Modified Gomory diagnosed as having polymyalgia rheumatica and trichrome staining (original magnification x 400). Two put on 20 mg/day of prednisone. Six months later, ragged red fibres are clearly seen in this field. the patient was no better and was referred to us. He showed clear proximal limb muscle atrophy. Muscle strength was IV-/V proximal and V/V distal. Usual biochemical blood analysis and muscle enzymes Case 2: trichromic cryostat stains also revealed a were normal as well as thyroid hormones and large quantity of ragged red fibres (6% in a cortisol. No evidence of lactic acidosis was found. 100 x magnification field), random fibre atrophy, An electromyographic study showed a myopathic and some fibre type grouping. Electron microscopy pattern. revealed clear changes of size and morphology of mitochondrial cristae. No muscle biochemical by copyright. Case 3 studies were available in this case. In case 3, 5% of ragged red fibres were found in A 78 year old woman without a remarkable family trichromical stains in a 100 x power field. NADH history developed intermittent diffuse myalgia and reaction revealed an abnormal oxidative pattern. moderate but slowly progressive proximal Electron microscopy also revealed subsarcolemmic weakness, involving mainly the pelvic girdle. Mus- mitrochondrial clusters with abnormal and bizarre cle strength was IV/V proximal in pelvic muscle, morphology (Figure 2). Some of these mitochon- but normal distally. Deep tendon reflexes were dria were giant, with cristae loss and osmiophilic normal. Muscle enzymes as well as endocrine and paracrystalline inclusions. State 3 respiratory studies were within the normal range. An electro- activity, respiratory control ratio and ADP/O http://pmj.bmj.com/ myographical study revealed a myopathic pattern index of these muscle mitochondria were normal in clinically affected muscles. on polarographic studies with different substrates Muscle studies Open left deltoid muscle biopsy was performed in on September 29, 2021 by guest. Protected all 3 cases. Processing included 8 gm cyrostat sections and routine histochemical stainings. A piece of muscle was fixed in glutaraldehyde and included in durcupan resin for semi-thin and ultrathin electron microscopy studies. Case 1: trichromic cryostat stains revealed a large quantity of ragged red fibres (5-6% in a 100 x magnification field) involving predomi- nantly type I fibres, a clear variability of fibre size and type II selective atrophy (Figure 1). Electron /e microscopy confirmed the mitochondrial abnor- Figure 2 Muscle deltoid biopsy. Electron microscopy mal pattern with changes on size and morphology (original magnification x 15,000). We can observe sub- of mitochondria and cristae, and osmiophilic sarcolemmal deposition of abnormal mitochondria. The mitochondrial inclusions. No biochemical muscle mitochondria appear rounded with loss of cristae and studies were available in this case. with occasional osmiophilic inclusions. Postgrad Med J: first published as 10.1136/pgmj.68.797.212 on 1 March 1992. Downloaded from 214 CLINICAL REPORTS (glutamate-malate, succinate-rotenone and in concordance with previous clinical series.822 ascorbate-TMDP) at 27°C. Only some patients with Kearns-Sayre syndrome A mitochondrial DNA study was performed in and external ophthalmoplegia show these features. all cases by established methods.'4 No deletions of Ragged red muscle have been described in many mitochondrial DNA were found. circumstances or even in otherwise normal muscle biopsies.23-26 For that reason, a very careful clinical and biological work-up must be done in all patients Discussion with this finding to rule out inflammatory, auto- immune, toxic, metabolic, neoplastic and endo- Munsat et al. first proposed in 1967 the term crine myopathies. Probably, in the near future, mitochondrial myopathy to describe many research in biochemical and neuromusclar fields different clinical diseases presenting with abnormal will allow other criteria for the diagnosis of the pathological muscle mitochondria.'5 Some years mitochondrial diseases in both young and adult- later, Shibasaki et al. described a 60 year old man onset types. These criteria will probably be based with a progressive proximal myopathy as the first on biochemical muscle findings, although for the case of adult-onset pure mitochondrial moment no clear pathological-biochemical rela- myopathy." Since then, many different clinical tionship has been described.'5'27 patterns of mitochondrial disease have been Because ofthe different clinical patterns seen, we reported,"'6-'8 the muscle pathology being a fre- presume there are also different pathogenetic quent finding in the context of multisystemic mechanisms. Some authors suppose a toxic28 or involvement, such as in Kearns-Sayre syndrome.'9 infectious29 origin. In one of our cases, a clear However, other clinical reports referring
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