Mitochondrial Myopathies

A typical human cell relies on hundreds of mitochondria to meet its energy needs. The symptoms of mitochondrial disease vary, because a person can have a unique mixture of healthy and defective mitochondria with a unique distribution in the body. In most cases, mitochondrial disease is a multisystem disorder affecting more than one type of cell, tissue or organ.

Because muscle and nerve cells have especially high energy needs, muscular and neurological problems are common features of mitochondrial disease. Other frequent complications include impaired vision, cardiac arrhythmia (abnormal heartbeat), diabetes and stunted growth. Usually, a person with a mitochondrial disease has two or more of these conditions, some of which occur together so regularly that they are grouped into syndromes.

In some individuals, weakness is most prominent in muscles that control movements of the eyes and eyelids. Two common consequences are the gradual paralysis of eye movements, called progressive external ophthalmoplegia (PEO), and drooping of the upper eyelids, called ptosis. Often people automatically compensate for PEO by moving their head to look in different directions and might not notice any visual problems. Ptosis can impair vision and cause a listless expression but can be corrected by surgery.

Mitochondrial myopathies also can cause weakness and wasting in other muscles of the face and neck, which can lead to difficulty with swallowing and, more rarely, slurred speech. People with mitochondrial myopathies also may experience muscle weakness in their arms and legs.

Exercise intolerance, also called exertional fatigue, refers to unusual feelings of exhaustion brought on by physical exertion. The degree of exercise intolerance varies greatly among individuals. Some people might have trouble only with athletic activities like jogging, while others might experience problems with everyday activities such as walking to the mailbox or lifting a milk carton.

Sometimes mitochondrial disease is associated with muscle cramps. In rare instances it can lead to muscle breakdown and pain after exercise. This breakdown causes leakage of a protein called myoglobin from the muscles into the urine (myoglobinuria). Cramps or myoglobinuria usually occur when someone with exercise intolerance “overdoes it” and can happen during the overexertion or several hours afterward.

While overexertion should be avoided, moderate exercise appears to help people with mitochondrial myopathy maintain strength.

A mitochondrial encephalomyopathy typically includes some of the symptoms of myopathy plus one or more neurological symptoms. Again, these symptoms vary greatly among individuals in both type and severity.

In addition to affecting eye muscles, a mitochondrial encephalomyopathy can affect the eye itself and parts of the brain involved in vision. For instance, vision loss, due to optic atrophy (shrinkage of the optic nerve) or retinopathy (degeneration of some of the cells that line the back of the eye), is a common symptom of mitochondrial encephalomyopathy.

Mitochondrial diseases are caused by genetic mutations. Genes provide the instructions for making proteins, and the genes involved in mitochondrial disease normally make proteins that work inside mitochondria. Within each mitochondrion, these proteins make up part of an assembly line that uses fuel molecules (sugars and fats) derived from food combined with oxygen to manufacture the energy molecule adenosine triphosphate, or ATP.

Proteins at the beginning of the assembly line import sugars and fats into the mitochondrion and then break them down to provide energy. Proteins toward the end of the line — organized into five groups called complexes I, II, III, IV and V — harness that energy to make ATP. This highly efficient part of the ATP manufacturing process requires oxygen and is called the respiratory chain. Some mitochondrial diseases are named for the part of the respiratory chain that is affected, such as complex I deficiency.

A cell filled with defective mitochondria becomes deprived of ATP and can accumulate a backlog of unused fuel molecules and destructive forms of oxygen called free radicals or reactive oxygen species. These are the targets of antioxidant compounds (found in many foods and nutritional supplements) that appear to offer general defenses against aging and disease.

In such cases, excess fuel molecules are used to make ATP by inefficient means, which can generate potentially harmful byproducts such as lactic acid. (This also occurs when a cell has an inadequate oxygen supply, which can happen to muscle cells during strenuous exercise.) The buildup of lactic acid in the blood — called lactic acidosis — is associated with muscle fatigue and might damage muscle and nerve tissue.

Muscle and nerve cells use the ATP derived from mitochondria as their main source of energy. The combined effects of energy deprivation and toxin accumulation in these cells can lead to many muscular and neurological symptoms.

The inheritance of mitochondrial diseases is complex, and often a mitochondrial myopathy can be difficult to trace through a family tree. In fact, many cases of mitochondrial disease are sporadic, meaning that they occur without any family history.

To understand how mitochondrial diseases are inherited, it is important to know that there are two types of genes essential to mitochondria. The first type is housed within the nucleus — a compartment within our cells that contains most of our genetic material, or DNA. The second type resides exclusively within DNA contained inside the mitochondria. Mutations in either nuclear DNA (nDNA) or mitochondrial DNA (mtDNA) can cause mitochondrial disease.

The risk of passing on a mitochondrial disease to a child depends on many factors, including whether the disease is caused by mutations in nDNA or mtDNA. To find out more about these risks, talk with a doctor or genetic counselor.

Some syndromes associated with mitochondrial disease are:

• Barth syndrome
  Onset: Infancy
  Features: Typical symptoms include cardiomyopathy, general muscle weakness and a low white blood cell count which leads to an increased risk of infection. This syndrome was once considered uniformly fatal in infancy, but some individuals are now living much longer.
• Chronic progressive external ophthalmoplegia (cPEO)
  Onset: Usually in adolescence or early adulthood
  Features: PEO is often a symptom of mitochondrial disease. In some people, it is a chronic, slowly progressive condition associated with instability to move the eyes and general weakness and exercise intolerance.
• Kearns-Sayre syndrome (KSS)
  Onset: Before age 20
  Features: PEO (usually as the initial symptom) and pigmentary retinopathy, a “salt-and-pepper” pigmentation in the retina that can affect vision. Other common symptoms include cardiomyopathy, conduction block (a type of cardiac arrhythmia) ataxia, short stature, neuropathy and deafness.
• Leigh syndrome (MILS, or maternally inherited Leigh syndrome)
  Onset: Infancy or early childhood
  Features: Brain abnormalities that can result in abnormal muscle tone, ataxia, seizures, impaired vision and hearing, developmental delays and respiratory problems. Infants with the disease have a poor prognosis.
• Mitochondrial DNA depletion syndromes (MDDS)
  Onset: Infancy
  Features: A myopathic form of MDDS is characterized by weakness that eventually affects the respiratory muscles. Some forms of MDDS, such as Alpers syndrome, are marked by brain abnormalities and progressive liver disease. The anticonvulsant sodium valproate should be used with caution in children with Alpers syndrome because it can increase the risk of liver failure.
• Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS)
  Onset: Childhood to early adulthood
  Features: The hallmarks of MELAS are encephalomyopathy with seizures and/or dementia, lactic acidosis and recurrent stroke-like episodes. These episodes are not typical strokes, which are interruptions in the brain's blood supply that cause sudden neurological symptoms. However, the episodes can produce stroke-like symptoms in the short term (such as temporary vision loss, difficulty speaking or difficulty understanding speech) and lead to progressive brain injury. The cause of the stroke-like episodes is unclear.
• Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE)
  Onset: Usually before age 20
  Features: This disorder is characterized by PEO, ptosis, limb weakness and gastrointestinal (digestive) problems, including vomiting, chronic diarrhea and abdominal pain. Another common symptom is peripheral neuropathy (a malfunction of the nerves that can lead to sensory impairment and muscle weakness).
• Myoclonus epilepsy with ragged red fibers (MERRF)
  Onset: Late childhood to adolescence
  Features: The most prominent symptoms of MERRF are myoclonus (muscle jerks), seizures, ataxia and muscle weakness. The disease also can cause hearing impairment and short stature.
• Neuropathy, ataxia and retinitis pigmentosa (NARP)
  Onset: Infancy to adulthood
  Features: NARP is caused by an mtDNA mutation that is also linked to MILS, and the two syndromes can occur in the same family. In addition to the core symptoms for which it is named, NARP can involve developmental delay, seizures and dementia. (Retinitis pigmentosa refers to a degeneration of the retina in the eye with resulting loss of vision.)
• Pearson syndrome
  Onset: Infancy
  Features: This syndrome involves severe anemia and malfunction of the pancreas. Children who have the disease usually go on to develop Kearns-Sayre syndrome.

Screening for mitochondrial myopathies typically involves a thorough medical evaluation, including collecting family history data. Doctors will also conduct a physical and neurological exam and run lab tests to screen for diabetes, liver and kidney problems.

Additionally, an electrocardiogram (EKG) may be performed to detect heart abnormalities, or diagnostic imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) to inspect the brain for developmental abnormalities or signs of damage.

Genetic testing can determine whether someone has a genetic mutation that causes mitochondrial disease. These tests use genetic material extracted from blood or from a muscle biopsy. Although a positive test result can confirm diagnosis of a mitochondrial disorder, a negative test result can be harder to interpret. It could mean a person has a genetic mutation that the test was not able to detect.

A typical human cell relies on hundreds of mitochondria to meet its energy needs. The symptoms of mitochondrial disease vary, because a person can have a unique mixture of healthy and defective mitochondria with a unique distribution in the body. In most cases, mitochondrial disease is a multisystem disorder affecting more than one type of cell, tissue or organ.

The main symptoms of mitochondrial myopathy are:

• Exercise intolerance
• Muscle fatigue
• Weakness

The severity of any of these symptoms varies greatly from one person to the next, even in the same family.

In some individuals, weakness is most prominent in muscles that control movements of the eyes and eyelids. Two common consequences are the gradual paralysis of eye movements, called progressive external ophthalmoplegia (PEO), and drooping of the upper eyelids, called ptosis. Often people automatically compensate for PEO by moving their head to look in different directions and might not notice any visual problems. Ptosis can impair vision and cause a listless expression but can be corrected by surgery.

Mitochondrial myopathies also can cause weakness and wasting in other muscles of the face and neck, which can lead to difficulty with swallowing and, more rarely, slurred speech. People with mitochondrial myopathies also may experience muscle weakness in their arms and legs.

Exercise intolerance, also called exertional fatigue, refers to unusual feelings of exhaustion brought on by physical exertion. The degree of exercise intolerance varies greatly among individuals. Some people might have trouble only with athletic activities like jogging, while others might experience problems with everyday activities such as walking to the mailbox or lifting a milk carton.

Sometimes mitochondrial disease is associated with muscle cramps. In rare instances it can lead to muscle breakdown and pain after exercise. This breakdown causes leakage of a protein called myoglobin from the muscles into the urine (myoglobinuria). Cramps or myoglobinuria usually occur when someone with exercise intolerance “overdoes it” and can happen during the overexertion or several hours afterward.

While overexertion should be avoided, moderate exercise appears to help people with mitochondrial myopathy maintain strength.

A diagnosis of mitochondrial myopathies generally includes:

• An evaluation of medical and family history
• Physical and neurological exams. The physical exam typically includes tests of strength and endurance, such as an exercise test (which can involve activities like repeatedly making a fist). The neurological exam can include tests of reflexes, vision, speech and basic cognitive (thinking) skills.
• Laboratory tests to look for diabetes, liver and kidney problems, and elevated lactic acid in the blood and urine. Some cases might warrant measuring lactic acid in the cerebral spinal fluid (CSF) that fills spaces within the brain and spinal cord. The measurement can be made by collecting CSF through a spinal tap or estimated by MR spectroscopy — a technique that uses an MRI signal to detect changes in the level of lactic acid and other chemicals in the brain.
• Electrocardiogram (EKG) to check the heart for signs of arrhythmia and cardiomyopathy
• Diagnostic imaging, such as computed tomography (CT) or magnetic resonance imaging (MRI) to inspect the brain for developmental abnormalities or signs of damage. In an individual who has seizures, the doctor might order an electroencephalogram (EEG), which involves placing electrodes on the scalp to record brain activity.
• Muscle biopsy, which involves removing and examining a small sample of muscle tissue. When treated with a dye that stains mitochondria red, muscles affected by mitochondrial disease often show ragged red fibers — muscle cells (fibers) that have excessive mitochondria. Other stains can detect the absence of essential mitochondrial enzymes in the muscle. It also is possible to extract mitochondrial proteins from the muscle and measure their activity. Noninvasive techniques, such as MR spectroscopy, can be used to examine muscle without taking a tissue sample.
• Genetic testing can determine whether someone has a genetic mutation that causes mitochondrial disease. These tests use genetic material extracted from blood or from a muscle biopsy. Although a positive test result can confirm diagnosis of a mitochondrial disorder, a negative test result can be harder to interpret. It could mean a person has a genetic mutation that the test was not able to detect.

Although there is no specific treatment for any of the mitochondrial myopathies, physical therapy may extend the range of movement of muscles and improve dexterity.

Instead of focusing on specific complications of mitochondrial disease, some treatments under investigation aim at fixing or bypassing the defective mitochondria. These treatments are nutritional supplements based on three natural substances involved in ATP production in our cells: creatine, carnitine and coenzyme Q10 (also known as CoQ10 or ubiquinone).

Scientists are investigating the possible benefits of exercise programs and nutritional supplements, primarily natural and synthetic versions of CoQ10. While CoQ10 has proven benefit for primary CoQ10 deficiency, it is unclear whether other nutritional supplements are useful for treating mitochondrial diseases.

Scientists have identified many of the genetic mutations that cause mitochondrial diseases. They have used that knowledge to create animal models of mitochondrial disease, which can be used to investigate potential treatments. Scientists also have designed genetic tests that allow accurate diagnosis of mitochondrial defects and provide valuable information for family planning. Knowing the genetic mutations that cause mitochondrial disease opens up the possibility of developing treatments that are specifically targeted.

Scientists hope to develop unique approaches to treating mitochondrial diseases through a better understanding of mitochondrial biology. Because people affected by mitochondrial disease often have a mixture of healthy and mutant mitochondria in their cells, effective therapy could involve getting the healthy mitochondria to take over. It might be possible to rescue mutant mitochondria by stimulating them to fuse with healthy mitochondria. Another approach might be to stimulate the birth of new mitochondria, encouraging the healthy ones to multiply and outnumber the mutants.

Consider participating in a clinical trial so clinicians and scientists can learn more about mitochondrial myopathies and related disorders. Clinical research uses human volunteers to help researchers learn more about a disorder and perhaps find better ways to safely detect, treat or prevent disease.

All types of volunteers — those who are healthy or may have an illness or disease — of all different ages, sexes, races, and ethnicities are needed to ensure that study results apply to as many people as possible and that treatments will be safe and effective for everyone who will use them.

For information about participating in clinical research visit NIH Clinical Research Trials and You. Learn about clinical trials currently looking for people with mitochondrial myopathies at Clinicaltrials.gov.