Familial Neonatal Isolated Cardiomyopathy Caused by a Mutation in the flavoprotein Subunit of Succinate Dehydrogenase
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European Journal of Human Genetics (2010) 18, 1160–1165 & 2010 Macmillan Publishers Limited All rights reserved 1018-4813/10 www.nature.com/ejhg ARTICLE Familial neonatal isolated cardiomyopathy caused by a mutation in the flavoprotein subunit of succinate dehydrogenase Aviva Levitas1,2,8, Emad Muhammad1,3,8, Gali Harel1,3,8, Ann Saada4, Vered Chalifa Caspi5, Esther Manor1,6, John C Beck7, Val Sheffield7 and Ruti Parvari*,1,3,5 Cardiomyopathies are common disorders resulting in heart failure; the most frequent form is dilated cardiomyopathy (DCM), which is characterized by dilatation of the left or both ventricles and impaired systolic function. DCM causes considerable morbidity and mortality, and is one of the major causes of sudden cardiac death. Although about one-third of patients are reported to have a genetic form of DCM, reported mutations explain only a minority of familial DCM. Moreover, the recessive neonatal isolated form of DCM has rarely been associated with a mutation. In this study, we present the association of a mutation in the SDHA gene with recessive neonatal isolated DCM in 15 patients of two large consanguineous Bedouin families. The cardiomyopathy is presumably caused by the significant tissue-specific reduction in SDH enzymatic activity in the heart muscle, whereas substantial activity is retained in the skeletal muscle and lymphoblastoid cells. Notably, the same mutation was previously reported to cause a multisystemic failure leading to neonatal death and Leigh’s syndrome. This study contributes to the molecular characterization of a severe form of neonatal cardiomyopathy and highlights extreme phenotypic variability resulting from a specific missense mutation in a nuclear gene encoding a protein of the mitochondrial respiratory chain. European Journal of Human Genetics (2010) 18, 1160–1165; doi:10.1038/ejhg.2010.83; published online 16 June 2010 Keywords: neonatal isolated cardiomyopathy; recessive inheritance; SDHA;mutation INTRODUCTION (FKTN). Defects in this gene also cause additional types of muscular Cardiomyopathies are the most common disorders resulting in heart dystrophies: the Fukuyama-type congenital muscular dystrophy, limb- failure. Dilated cardiomyopathy (DCM; MIM 115200) is characterized girdle muscular dystrophy type 2M, and the Walker–Warburg by cardiac dilatation and reduced systolic function. DCM is the most syndrome. (3) CMD2A (OMIM 611880) was reported in one family; frequent form of cardiomyopathy and the major cause of cardiac the disease appeared in the second decade of life and is caused by transplantation in children, accounting for 450% of all cardiac a mutation in the gene encoding the cardiac structural component transplantations performed in patients between 1 and 10 years of troponin I (TNNI3). (4). A myopathy with fatal cardiomyopathy age. Many factors may contribute to the development of this disorder, (OMIM 611705) reported in one family is caused by mutation in the although most commonly the etiology is unknown. A heritable gene encoding titin (TTN). Mitochondrial dysfunction frequently pattern is present in 20–30% of the cases;1 however, reported muta- affects the heart and may cause both hypertrophic cardiomyopathy tions explain only a minority of familial DCM.2 Although diverse and DCM.3 Nuclear encoded genes affecting mitochondrial functions modes of inheritance have been demonstrated, most familial DCM are known to cause DCM. For example, a rare genetic disorder of the pedigrees show an autosomal dominant pattern of inheritance, usually fatty acid b-oxidation cycle caused by mutations in both alleles of the presenting in the second or third decade of life. DCM with recessive a-subunit (HADHA) of the mitochondrial trifunctional protein may inheritance has been described five times and the affected genes result in a severe neonatal cardiomyopathy with hypoketotic hypo- identified in four of the cases: (1) CMD3a, a fatal congenital DCM glycemia and hepatic encephalopathy, often progressing to coma and reported in one family (OMIM 300069) (Online Mendelian Inheri- neonatal death.4,5 Another example is the recent finding of a nonsense tance in Man (OMIM) http://www.ncbi.nlm.nih.gov/OMIM)), is mutation in Coenzyme Q10, a mobile lipophilic electron carrier caused by mutations in tafazin (the function of this gene is not located in the inner mitochondrial membrane. The mutation results known). Mutations in this gene also cause Barth’s syndrome (OMIM in multisystem disease, including cardiomyopathy.6 302060). (2) CMD1X (OMIM 611615) with or without mild proximal Succinate dehydrogenase (SDH, E.C. 1.3.5.1) deficiency is a rare muscle weakness, caused by mutations in the gene encoding fukutin condition in humans, representing 2% of mitochondrial respiratory 1Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; 2Pediatric Cardiology Department, Soroka Medical Center, Beer-Sheva, Israel; 3Faculty of Health Sciences, Department of Virology and Developmental Genetics, Ben-Gurion University of the Negev, Beer-Sheva, Israel; 4Department of Human Genetics and Metabolic Diseases, Hadassah–Hebrew University Medical Center, Jerusalem, Israel; 5National Institute of Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer-Sheva, Israel; 6Institute of Genetics, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel; 7Division of Medical Genetics, Department of Pediatrics, Howard Hughes Medical Institute, University of Iowa, Iowa City, IA, USA *Correspondence: Professor R Parvari, Faculty of Health Sciences, Department of Virology and Developmental Genetics, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel. Tel: +972 8 647 9967; Fax: +972 8 627 6215; E-mail: [email protected] 8These authors contributed equally to this work. Received 28 January 2010; accepted 21 April 2010; published online 16 June 2010 SDHA mutation in isolated neonatal cardiomyopathy ALevitaset al 1161 chain (RC) disorders.7 Its clinical presentation is highly variable, alkaline phosphatase 0.6U and 6U Exonuclease I (both from Fermentas, ranging from early-onset encephalomyopathies to tumor susceptibility Vilnius, Lithuania). in adults.8,9 SDH catalyzes the conversion of succinate to fumarate and The mutation was identified on genomic DNA by direct sequencing of a is a component of the mitochondrial RC (complex II) and the Krebs PCR product using primers, forward: GTGCACACTGTTGGGCCCTT and cycle. SDH is composed of four subunits, all encoded in the nuclear reverse: GCCCCGTGACTCCTTCCGT, which amplify exon 13, the mutation changing the first nucleotide in this exon. The 3¢ first nucleotide and two DNA – two soluble proteins, the flavoprotein (Fp, SDHA), and the Fe-S nucleotides of the forward and reverse primers, respectively, are unique to protein (SDHB) – which are anchored to the inner membrane by chromosome 5 and do not exist on the pseudogene SDHA gene on chromo- 8,9 subunits SDHC and SDHD. Pathogenic mutations in the SDHA gene some 3. Under the amplification conditions of 30 cycles of 941 1¢,601 1¢,and have rarely been documented in children, and all but one case have 721 1¢, only the sequence of chromosome 5 is amplified. This was validated by been reported in patients with Leigh’s syndrome.7,10–12 The single case BLAST analysis revealing 100% identity to chromosome 5 and the 11 nucleo- not presenting with Leigh’s syndrome describes death at infancy, before tides differences form the sequence of chromosome 3. any sign of the syndrome could be detected, following a respiratory infection and severe hypoglycemia.13 A late-onset neurodegenerative RESULTS disease with progressive optic atrophy, ataxia, and myopathy was Patients tentatively ascribed to a heterozygous mutation in a conserved region In all, 15 Bedouin patients of one tribe who presented with cardio- of the SDHA protein.14 In this report, we present the association of a myopathy, between the ages of 32 weeks in utero to 10 years of age, mutation in the SDHA gene with the clinical manifestation and were enrolled. The laboratory indices were normal except for mildly interfamilial variability of 15 patients diagnosed with DCM. increased lactate of 3.7 mmol/l. The electrocardiogram of all patients was sinus rhythm with LV hypertrophy and normal QTC interval. METHODS Cardiomyopathies were categorized according to World Health 27 Patients Organization cardiomyopathy classification. At presentation, all The study was approved by the Soroka Medical Center Review Board. The patients had normal growth (30th–50th percentile) and a normal patients’ medical records were carefully reviewed, and details of their somatic neuromuscular examination, including muscle bulk and strength, growth, psychomotor development, clinical course, hospitalizations, and reflexes, and gait. The psychomotor development was appropriate laboratory results were recorded. Their parents and siblings were interviewed for age. During follow-up visits, the neuromuscular examinations and underwent a complete physical examination (particularly focused on the remained normal and none of the patients had seizures. In two cardiac and neuromuscular systems). The patients’ evaluation included: echo- patients, a brain MRI was performed without any evidence of cardiology: transthoracic two-dimensional and Doppler echocardiography focal lesions in the basal ganglia or grey matter or cortex or performed using a System Vivid 7 echocardiograph (GE Medical Systems, brainstem, ruling out Leigh’s syndrome. Eight infants were diagnosed Saskatchewan,