III

Georgia Neurological SocietyAnnual Meeting 2011

Neurometabolic Disease in Adult Neurologic Practice

CI

IIIII IV VCoQ10

ADP ATPNADHNAD+

O2H2O

H+ H+ H+ H+

H+

Research Grants2009-2010 Department of Defense, Grant: Mitochondrial Defects in

Autism AR080046

2009-2012 Department of Defense, Grant: Mechanisms of mitochondrial defects in Gulf War Syndrome GW080138

2010-2013 Department of Defense, Grant: Mechanisms of mitochondrial dysfunction in autism. Combined laboratory analysis and functional MRI assessments. AR093329

2010-2011 PND Association Research Grant Program titled "Keratinocytes and / or melanocytes as a cell source for the enzyme assay of tyrosine hydroxylase"

2005-2010 Subcontract for NIH HPA grant (UO1 AI057565): Hyperphenylalaninemia in cerebral malaria

Cerebral Folate Defects

Mitochondrial Diseases

Treatment

Cerebral Folate Defects: Definition

What are cerebral folate defects and how are they diagnosed?

Any neurological syndrome associated with a low CSF 5-methyltetrahydrofolate (5-MTHF) (<50 mmol/L) in the presence of NORMAL peripheral folate status.

(Dev Med Child Neurol 46:843;2004)

If diagnosed early enough, these defects are treatable.

Cerebral Folate Defects: Causes

What causes cerebral folate defects?Genetic DiseaseDrugsAutoimmune Disease

Cerebral folate defects affect ALL AGE GROUPS.

For more detailed information about various conditions causing CFD, email me at:

[email protected]

Hyland K, Shoffner J, Heales SJ.J Inherit Metab Dis. 2010 Oct;33(5):563-70

Cerebral Folate Defects: Symptoms

What are the symptoms of CFD?

DemyelinationEpilepsy (essentially all types)Movement disordersNeuropathiesNeurobehavioral (autism) and psychiatric disordersCognitive impairment and mental retardationSpasticity

NOT ANEMIA IN MOST CASES !!!Symptoms evolve over time

Cerebral Folate Defects: Mechanisms

5-MTHF

Choroid PlexusPlasma CSF

5-MTHFFR1

Folate PolyglutamatePool

RFC

5-MTHF = 5-methyltetrahydrofolate; FR1 = Folate receptor 1; RFC = Reduced Folate Carrier

ATP

3-4xHigher thanplasma

Cerebral Folate Defects: Causes

Drugs(e.g. L-Dopa,

methotrexate)

Genetic Disease

(e.g. Mitochondrial Disease, FOLR1

mutations, and many more)

Autoimmune Disease

(Antibodies to Folate Receptor)

ATP production

Free radical generation

Apoptosis

Mitochondrial/Endoplasmic Reticulum Calcium regulation

Effects on other metabolic pathways

Toxic interactions

Mitochondrial DiseaseNot just a defect in ATP production

Glucose + Fatty Acids = ATP!

CI

IIIII IV VCoQ10

ADP ATPANT

POR

ATP

ATP ADP

NADHNAD+

O2H2OADP

H+ H+ H+ H+

H+

GLYCOGEN

Fatty Acids

Long Chain (C14-C20)

CPT II

L-Carnitine

Medium Chain

Short Chain

Medium Chain (C8-C12)

Short Chain (C4-C6)

VLCADLong Chain

(C14-C20)

Acetyl -CoA

-oxidation

CPT I

TCA

Pyruvate

GLYCOLYSIS

Acetyl -CoA

Pyruvate PDHC

LactateAlanine

Complex I Complex III

Complex IV

HOW IT REALLY WORKS:SUPERCOMPLEXES

Stability and AssemblyJ Biol Chem 279;36349,2004

Supercomplexes + Monomeric OXPHOS EnzymesBlue Native Electrophoresis

Normal Patient 1 Patient 3 Pediatric Adult SURF1 SURF1

Dimeric CV

Monomeric CV

Dimeric CIII

Monomeric CIV

I1III2IVn + CVn

I1III2IV1CI1CIII2

* *The higher molecular weight bands may be

oligomeric forms of Complex V.

Complex I Complex III

Complex IV

Complex IV: CLEAR NATIVE GEL Monomeric OXPHOS Enzyme Assembly

Monomeric Complex IV

Normal Patient 1 Patient 2 Normal Pediatric Pediatric

*

*

*

*

Monomeric Complex IV

Normal Patient 2 Patient 3 Normal Pediatric Adult

Mitochondrial Disease: Treatment

Irreversible Reversible Normal

Mitochondrial Dysfunction: Threshold Expression

Phenotype

OXPHOSFunction

Normal

NormalAbnormal

• Kearnes-Sayre Syndrome• Sporadic mtDNA Deletion• Abnormal choroid plexus

Progressive loss of balance and motor function. Became confined to bed over several

months.

CSF 5-MTHF 8 (NL 50-120)CFD observed in over 80% of Kearnes-Sayre

cases

Cerebral Folate Deficiency: AdolescentMitochondrial disease: Adolescent

Genetic Diagnosis

Rapidly Evolving:mtDNA ----16,569 nucleotidesNuclear DNA----~1400 genes

Next Generation Sequencing

Kearnes-Sayre Syndrome

Cerebral Folate Deficiency: AdolescentMitochondrial disease: Adolescent

Treatment with Leucovorin (Folinic acid) 25mg po bid.

Resolution of symptoms and return to baseline: Walking independently, going to school, complete self care

Cerebral Folate Deficiency: AdolescentMitochondrial disease: Adolescent

Fatigue and MyalgiasCerebral Folate Deficiency: Adult OnsetMitochondrial disease: Adult Onset

41 year old woman

20-25 years: Less endurance than peers26 years – present:

Progressive fatigue, severely limiting activity36 years: Distal pain, paresthesias in hands and feet; Cognitive complaints (calculations, word retrieval, memory)

Brain and spinal cord imaging: NegativeEMG/NCV: NegativeRheumatological Testing: Negative

Two sons: One healthy (9 years old). One with muscle weakness, leg cramps, myopathic EMG, normal CPK.

Exercise Testing: Essential for diagnosing and

following fatigue

Anaerobic Threshold (AT)Patient: 10 ml/kg/min

Predicted: >11 ml/kg/min

Peak VO2 MaxPatient: 1.44 L/min

Predicted: ≥ 1.83 L/Min

Predicted normal ranges:Based on age, gender, weight, height, BMI)Normal Pulmonary Function Testing

Exercise Testing: Met-Test

Fatigue and MyalgiasCerebral Folate Deficiency: Adult OnsetMitochondrial disease: Adult Onset

Muscle Biopsy: Sarcoplasmic Masses

Epidermal Nerve Fiber Density: Decreased consistent with a small fiber neuropathy

CSF 5-methyltetrahydrofolate: 25 (NL >50 mmol/L)CSF protein: 45 (NL 15-45)

Mitochondrial DiseaseCSF Alanine: 44.9 µmol/L (NL 20.8-35.4 µmol/L)Muslce Biochemistry: Complex I and Complex III Defect

Fatigue and MyalgiasCerebral Folate Deficiency: Adult OnsetMitochondrial disease: Adult Onset

Genetics:Mitochondrial DNA (nuclear and mtDNA)Pending

FOLR1 (Folate Receptor)Single mutation in Exon 3: c.352C>T P.Q118X Stop codon producing a truncated proteinMay increase susceptibility to developing a cerebral folate defect

Fatigue and MyalgiasCerebral Folate Deficiency: Adult OnsetMitochondrial disease: Adult Onset

Folinic acid Treatment:25mg PO every 8 hours

Improved neuropathic symptoms:Pain and dysaesthesias

Improved episodes with difficulty thinking (calculations, word retrieval, memory)

A retrospective analysis of evaluations performed on 62 patients was performed.

36 adults (>19 years) (11 male; 25 female)Mean age ± SD = 39.2 ± 9.2 years;

Median = 39.5 years; Range 20-60 years

Adult Onset Fatigue and Myalgias Syndromes

ADULT FATIGUE + MYALGIASWeakness 17% (6/36)

Increased CPK 17% (6/36)Rhabdomyolysis 14% (5/36)

Abnormal Metabolic Testing 28% (10/36)Abnormal OXPHOS Enzymology 83% (30/36)Abnormal OXPHOS Western Blot 48% (14/29)

Abnormal Muscle CoQ10 (Deficiency) 41% (7/17)Abnormal mtDNA Copy Number 7% (2/27)Pathogenic mtDNA mutations 8% (2/26)

Provisionally Pathogenic mtDNA mutation 27% (7/26)

Fatty acid oxidation diseases, glycogen storage diseases, autoimmune disease, congenital myopathies and muscular

dystrophies were excluded.

Coenzyme Q10: Mildly effective Exception: Primary (genetic) CoQ10 deficiency. Response can be dramatic.

Clinical investigations:EPI-743 (Edison Pharmaceutical): Effect not clear in Leigh Disease (2 patients). Drug currently under study

Other companies: Collaboration moving forward on agents showing improvements in cells with mitochondrial dysfunction

Mitochondrial Disease Treatment

Mitochondrial ATP Generation: Medical Neurogenetics Research

Mitochondrial and Cytoplasmic Luciferase

Georgia Neurological SocietyAnnual Meeting 2011

Neurometabolic Disease in Adult Neurologic Practice

CI

IIIII IV VCoQ10

ADP ATPNADHNAD+

O2H2O

H+ H+ H+ H+

H+

Thank You!