Mitochondrial Diseases - nbt.nhs.uk
Transcript of Mitochondrial Diseases - nbt.nhs.uk
![Page 1: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/1.jpg)
Mitochondrial Diseases
Simon Heales
SWIM Conference – Taunton, November 29th 2018
![Page 2: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/2.jpg)
Diabetes Thyroid
Disease Myopathy
Peripheral
Neuropathy
Deafness
Seizures /
Developmental delay
Respiratory Failure Optic Atrophy / Retinitis
Pigmentosa
Cardiomyopathy
Short Stature
Marrow Failure
Liver
Failure
Red Flags
![Page 3: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/3.jpg)
1 in 5,000
![Page 4: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/4.jpg)
Heteroplasmy & oogenesis
Gorman, G. S. et al. (2016) Mitochondrial diseases
Nat. Rev. Dis. Primers doi:10.1038/nrdp.2016.80
Adapted from Taylor, R. W. & Turnbull, D. M. Mitochondrial DNA
mutations in human disease. Nat. Rev. Genet. 6, 389–402 (2005), Nature Publishing Group
![Page 5: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/5.jpg)
![Page 6: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/6.jpg)
Clinical Picture
Biochemistry
Histochemistry
Genetics
Neuroimaging
![Page 7: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/7.jpg)
Phenotypic Syndromes • Leigh syndrome
• Alpers syndrome
• Mitochondrial recessive ataxia syndrome
• Mitochondrial encephalomyopathy, lactic acidosis & stroke like episodes
(MELAS)
• Myoclonic epilepsy with ragged red fibres (MERFF)
• Pearson syndrome
• Kearns-Sayre syndrome (KSS)
• Progressive external ophthalmoplegia (PEO)
• Leber hereditary optic neuropathy (LHON)
• Neuropathy, ataxia and retinitis pigmentosa (NARP)
• Mitochondrial neurogastrointestinal encephalopathy (MNGIE)
• Myopathy lactic acidosis and sideroblastic anaemia (MLASA)
![Page 8: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/8.jpg)
![Page 9: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/9.jpg)
Metabolic Biochemistry
• Lactate – normal levels do not exclude. Secondary factors.
• Plasma amino acids, e.g. alanine
• Plasma acylcarnitines – differential diagnosis.
• Urine organic acids – lactate, TCA cycle intermediates,
ethylmalonic acid, 3-methylglutaconic acid, methylmalonic
acid (SUCLA2).
• FGF21
• GDF15
![Page 10: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/10.jpg)
Diagnostic algorithm for suspected mitochondrial
diseases
Gorman, G. S. et al. (2016) Mitochondrial diseases
Nat. Rev. Dis. Primers doi:10.1038/nrdp.2016.80
![Page 11: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/11.jpg)
Muscle Biopsy
• Skeletal muscle (50 - 100mg).
• Flash frozen at bedside.
• Store at -70oC.
• Transported on dry ice.
• Store at -70oC.
• Homogenise (1:9 w/v)
• Freeze Thaw (x3).
• Assay.
![Page 12: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/12.jpg)
Citrate Synthase a Marker of Mitochondrial Enrichment
![Page 13: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/13.jpg)
Mitochondrial Complex
Assays
I III II
IV
NADH
NAD+
Q
QH2
Succinate
Fumarate
Cyt c (Ox)
Cyt c (Red)
Cyt c (Red)
Cyt c (Ox)
O2
H2O
Rotenone Anitmycin
Cyanide
Q
![Page 14: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/14.jpg)
Case
• 7 days; history of poor feeding and lethargy.
Elevated serum lactate and hypoglycaemia.
• 3 weeks; right-sided twitching episodes. EEG
revealed asymmetric discharges. MRI normal.
TCA cycle intermediates present in urine.
• 7 weeks: Skin, liver and muscle obtained
![Page 15: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/15.jpg)
Muscle Respiratory Chain
Enzymes
Complex I 0.042 (0.104 - 0.268)
Complex II/III 0.156 (0.040 - 0.204) Complex IV 0.023 (0.014 - 0.034)
![Page 16: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/16.jpg)
Liver Respiratory Chain
Enzymes
Complex I 0.017 (0.043 - 0.127)
Complex II/III 0.033 (0.037 - 0.099) Complex IV 0.018 (0.004 - 0.023)
![Page 17: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/17.jpg)
Fatty Acid Oxidation Studies
• Fibroblasts - Sheffield
• All chain length activities depressed
• Can support diagnosis of mitochondrial defect
![Page 18: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/18.jpg)
V (F0+ F1)
F1
Blue Native Gel Electrophoresis
Complex V Activity
Pooled control Patient
![Page 19: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/19.jpg)
I
V III
IV
II Absent complex III
Blue Native Gel Electrophoresis
![Page 20: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/20.jpg)
• Acute regression of motor skills. MRI brain demonstrates bilateral, symmetrical high signal in the basal ganglia and brain stem suggestive of Leigh's syndrome. Also noted to be some thinning of optic chiasm.
• CSF lactate = 3.2 and serum lactate = 4 and 2.51 on repeat. • Current medication: Biotin 30mg bd, Thiamine 100mg tds and Ubiquinone 25mg bd.
Case
![Page 21: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/21.jpg)
NDUFV1 mutation.
![Page 22: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/22.jpg)
Oxidative Phosphorylation – CoQ and Cytochrome c
Gorman, G. S. et al. (2016) Mitochondrial diseases
Nat. Rev. Dis. Primers doi:10.1038/nrdp.2016.80
![Page 23: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/23.jpg)
Neonatal presentation of CoQ10
Deficiency. J. Pediatr; 139: 456-458
• Presented at 6 hrs with poor feeding, hypothermia and shaking of both arms. Generalised increase in peripheral tone with reduced truncal tone.
• Initial investigations; lactic acidosis (plasma lactate 19.4 mmol/L). Renal tubulopathy and mild left ventricular hypertrophy with global hypokinesia. Brain MRI demonstrated generalised atrophy and cerebellar atrophy.
![Page 24: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/24.jpg)
Muscle Complex II+III
III II
Succinate
Fumarate
Cyt c (Ox)
Cyt c (Red)
Anitmycin
Q
Complex Activity Ref Range
II+III <0.001 0.040-0.204
II 0.151 0.052-0.258
III 0.026 0.008-0.028
CoQ10 37* (140-580 pmol/mg)
![Page 25: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/25.jpg)
•Oral CoQ10 therapy
60 to 300 mg/day
•Decreased plasma lactate
7.6 to 2.5 mmol/L after 4 months
•Not accompanied by clinical improvement
![Page 26: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/26.jpg)
• Secondary muscle
CoQ10 Deficiency
associated with
mitochondrial
respiratory chain
defects.
• Reported benefits from
supplementation.
![Page 27: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/27.jpg)
Groups Cytosolic
Cytochrome C
ng/mg protein
ETC Defects
(n=22)
63.7 ± 15.5*
Disease
Controls
(n=26)
27.7 ± 2.5
![Page 28: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/28.jpg)
Methionine
Homocysteine
Adomet
Cystathionine
Cysteine
B12 Methyl-cbl MS
Methyl-THF
THF
Serine Diet
B6 CBS
MAT
Glycine
Betaine
DMG
X
Methyl-X
Cbl(II)
Methyl-cbl
Methyl transferases
SH
MT
Ado.hcy
Gly
Sar
GNMT
![Page 29: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/29.jpg)
N
N
N
NH
NH2
NH
O
NH
O OH
OH
O
OH CH3
5-Methyltetrahydrofolate
•CSF deficiency documented in mitochondrial disorders
(Allen et al., 1983, Dougados et al., 1983)
•Responsive to folinic acid
•No apparent correlation with magnitude of defect
![Page 30: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/30.jpg)
CSF 5-MTHF Deficiency & Mitochondrial
Respiratory Chain Defects
Sex Age (years) 5-MTHF Ref Range (nmol/L)
F 15 29 46 - 160
M 9 5 72 - 172
M 8 44 72 - 172
F 2 17 52 - 178
F 6 7 72 - 172
Associated in some (25%) but not all patients
![Page 31: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/31.jpg)
5MTHF Endocytosis
Folate Polyglutamate
Pool
5MTHF FR1
RFC
sFR1
-ve
PLASMA CSF
1 2
O2
._
5MTHF ???
![Page 32: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/32.jpg)
FGF21
![Page 33: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/33.jpg)
FGF21
Al Shahrani et al. Unpublished
![Page 34: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/34.jpg)
![Page 35: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/35.jpg)
Decanoic Acid & Function
0
0.2
0.4
0.6
0.8
1
1.2
1.4
ControlC10
Re
lati
ve m
tDN
A c
on
ten
t
Control
C10 Treated
![Page 36: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/36.jpg)
Specimen
Reception Biobank Trials, Research
Combined Omics
Platforms
Personalised Testing
Integrated
Comprehensive Report
?
![Page 37: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/37.jpg)
Flow Chart Showing Gene-Discovery Approach with the Use of Collaborative Phenomics and Semiautomated Genomics.
Tarailo-Graovac M et al. N Engl J Med 2016;374:2246-2255
![Page 38: Mitochondrial Diseases - nbt.nhs.uk](https://reader031.fdocuments.in/reader031/viewer/2022012920/61c756a36491934bf67e7912/html5/thumbnails/38.jpg)
Amanda Lam
Stuart Bennett
Iain Hargreaves
Viruna Neergheen
Simon Pope
Acknowledgements
Simon Eaton
Michael Orford
Aziza Khabbush
Tom Baldwin
Sean Hughes
Marta Kanabus
Shamima Rahman