Duchenne muscular dystrophy pathophysiology: Difference between revisions
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==Pathophysiology== | ==Pathophysiology== | ||
===Physiology=== | ===Physiology=== | ||
The normal [[physiology]] of [[dystrophin]] protein can be understood as follows: | The normal [[physiology]] of [[dystrophin]] protein can be understood as follows:<ref name="PéréonMercier2015">{{cite journal|last1=Péréon|first1=Y.|last2=Mercier|first2=S.|last3=Magot|first3=A.|title=Physiopathologie de la dystrophie musculaire de Duchenne|journal=Archives de Pédiatrie|volume=22|issue=12|year=2015|pages=12S18–12S23|issn=0929693X|doi=10.1016/S0929-693X(16)30004-5}}</ref><ref name="BlakeWeir2002">{{cite journal|last1=Blake|first1=Derek J.|last2=Weir|first2=Andrew|last3=Newey|first3=Sarah E.|last4=Davies|first4=Kay E.|title=Function and Genetics of Dystrophin and Dystrophin-Related Proteins in Muscle|journal=Physiological Reviews|volume=82|issue=2|year=2002|pages=291–329|issn=0031-9333|doi=10.1152/physrev.00028.2001}}</ref> | ||
* [[Dystrophin]] protein is a part of the [[protein]] complex named [[dystrophin-associated protein complex]] ([[Dystrophin-associated protein complex|DAPC]]) which acts as an anchor that connect the intracellular [[cytoskeleton]] proteins such as [[Dystrobrevin|α-dystrobrevin]], [[syncoilin]], [[synemin]], [[sarcoglycan]], [[dystroglycan]], and [[sarcospan]] to the [[extracellular matrix]]. | * [[Dystrophin]] protein is a part of the [[protein]] complex named [[dystrophin-associated protein complex]] ([[Dystrophin-associated protein complex|DAPC]]) which acts as an anchor that connect the intracellular [[cytoskeleton]] proteins such as [[Dystrobrevin|α-dystrobrevin]], [[syncoilin]], [[synemin]], [[sarcoglycan]], [[dystroglycan]], and [[sarcospan]] to the [[extracellular matrix]]. | ||
* This [[protein]] guaranties [[muscle]] strength and integrity. | * This [[protein]] guaranties [[muscle]] strength and integrity. | ||
* The absence of this [[protein]] or misfolded [[protein]] leads to decreased strength, increased [[instability]], and [[deformity]] of [[sarcolemma]]. | * The absence of this [[protein]] or misfolded [[protein]] leads to decreased strength, increased [[instability]], and [[deformity]] of [[sarcolemma]]. | ||
[[File:748px-1022 Muscle Fibers (small).jpg|500px|none|thumb|https://librepathology.org/wiki/File:1022_Muscle_Fibers_(small).jpg]] | |||
===Pathogenesis=== | ===Pathogenesis=== | ||
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* | * | ||
==Genetics== | ==Genetics== | ||
* Duchenne [[muscular dystrophy]] is transmitted in [[X linked inheritance|X-link recessive]] pattern. | * Duchenne [[muscular dystrophy]] is transmitted in [[X linked inheritance|X-link recessive]] pattern.<ref name="TowbinHejtmancik1993">{{cite journal|last1=Towbin|first1=J A|last2=Hejtmancik|first2=J F|last3=Brink|first3=P|last4=Gelb|first4=B|last5=Zhu|first5=X M|last6=Chamberlain|first6=J S|last7=McCabe|first7=E R|last8=Swift|first8=M|title=X-linked dilated cardiomyopathy. Molecular genetic evidence of linkage to the Duchenne muscular dystrophy (dystrophin) gene at the Xp21 locus.|journal=Circulation|volume=87|issue=6|year=1993|pages=1854–1865|issn=0009-7322|doi=10.1161/01.CIR.87.6.1854}}</ref><ref name="BertelsonBartley1986">{{cite journal|last1=Bertelson|first1=C J|last2=Bartley|first2=J A|last3=Monaco|first3=A P|last4=Colletti-Feener|first4=C|last5=Fischbeck|first5=K|last6=Kunkel|first6=L M|title=Localisation of Xp21 meiotic exchange points in Duchenne muscular dystrophy families.|journal=Journal of Medical Genetics|volume=23|issue=6|year=1986|pages=531–537|issn=1468-6244|doi=10.1136/jmg.23.6.531}}</ref><ref name="LindenbaumClarke1979">{{cite journal|last1=Lindenbaum|first1=R H|last2=Clarke|first2=G|last3=Patel|first3=C|last4=Moncrieff|first4=M|last5=Hughes|first5=J T|title=Muscular dystrophy in an X; 1 translocation female suggests that Duchenne locus is on X chromosome short arm.|journal=Journal of Medical Genetics|volume=16|issue=5|year=1979|pages=389–392|issn=1468-6244|doi=10.1136/jmg.16.5.389}}</ref> | ||
* [[Gene]] involved in the [[pathogenesis]] of Duchenne [[muscular dystrophy]] is Xp21 [[gene]], which encodes the [[protein]] [[dystrophin]]. | * [[Gene]] involved in the [[pathogenesis]] of Duchenne [[muscular dystrophy]] is Xp21 [[gene]], which encodes the [[protein]] [[dystrophin]]. | ||
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* The sons of [[carrier]] [[Female|females]] each have a 50% chance of having the [[disease]], and the daughters each have a 50% chance of being [[Carrier|carriers]]. | * The sons of [[carrier]] [[Female|females]] each have a 50% chance of having the [[disease]], and the daughters each have a 50% chance of being [[Carrier|carriers]]. | ||
* Daughters of [[men]] with Duchenne will always be [[Carrier|carriers]], since they will inherit an affected [[X chromosome]] from their father. | * Daughters of [[men]] with Duchenne will always be [[Carrier|carriers]], since they will inherit an affected [[X chromosome]] from their father. | ||
* Some [[Female|females]] will also have very mild degrees of [[muscular dystrophy]], and this is known as being a manifesting [[carrier]]. | * Some [[Female|females]] will also have very mild degrees of [[muscular dystrophy]], and this is known as being a manifesting [[carrier]].<ref name="MoserEmery2008">{{cite journal|last1=Moser|first1=H.|last2=Emery|first2=A. E. H.|title=The manifesting carrier in Duchenne muscular dystrophy|journal=Clinical Genetics|volume=5|issue=4|year=2008|pages=271–284|issn=00099163|doi=10.1111/j.1399-0004.1974.tb01694.x}}</ref> | ||
* In one-third of the cases, the [[disease]] is a result of an unspontaneous or new [[mutation]]. | * In one-third of the cases, the [[disease]] is a result of an unspontaneous or new [[mutation]]. | ||
* [[Prenatal testing]], such as [[amniocentesis]], for pregnancies at risk is possible if the DMD disease-causing mutation has been identified in a family member or if informative linked markers have been identified. | * [[Prenatal testing]], such as [[amniocentesis]], for [[Pregnancy|pregnancies]] at risk is possible if the DMD disease-causing [[mutation]] has been identified in a family member or if informative linked markers have been identified.<ref name="MahoneyHaseltine1977">{{cite journal|last1=Mahoney|first1=Maurice J.|last2=Haseltine|first2=Florence P.|last3=Hobbins|first3=John C.|last4=Banker|first4=Betty Q.|last5=Caskey|first5=C. Thomas|last6=Golbus|first6=Mitchell S.|title=Prenatal Diagnosis of Duchenne's Muscular Dystrophy|journal=New England Journal of Medicine|volume=297|issue=18|year=1977|pages=968–973|issn=0028-4793|doi=10.1056/NEJM197711032971803}}</ref> | ||
* The dystrophin gene contains 24 regions of 109 amino acids that are similar but not exact, making it susceptible to misalignment at the [[Meiosis|meiotic]] synapse, which can lead to [[Frameshift mutation|frameshift mutations]] and an untranslatable gene. | * The [[dystrophin]] gene contains 24 regions of 109 [[Amino acid|amino acids]] that are similar but not exact, making it susceptible to misalignment at the [[Meiosis|meiotic]] synapse, which can lead to [[Frameshift mutation|frameshift mutations]] and an untranslatable gene. | ||
* This can happen with a frequency of about 1 in 10,000. | * This can happen with a frequency of about 1 in 10,000. | ||
* In some female cases, DMD is caused by skewed [[X inactivation]]. | * In some [[female]] cases, DMD is caused by skewed [[X inactivation]]. | ||
* In these cases, two copies of the X chromosome exist, but for reasons currently unknown, the flawed X chromosome manifests instead of the unflawed copy. | * In these cases, two copies of the [[X chromosome]] exist, but for reasons currently unknown, the flawed [[X chromosome]] manifests instead of the unflawed copy. | ||
* In these cases, a mosaic form of DMD is seen, in which some muscle cells are completely normal while others exhibit classic DMD findings. | * In these cases, a [[Mosaic (genetics)|mosaic]] form of DMD is seen, in which some [[muscle cells]] are completely normal while others exhibit classic DMD findings. | ||
* The effects of a mosaic form of DMD on long-term outlook is not known. | * The effects of a mosaic form of DMD on long-term outlook is not known. | ||
[[File:474px-Ideogram human chromosome X.svg.png|500px|none|thumb|https://en.wikipedia.org/wiki/File:Ideogram_human_chromosome_X.svg]] | [[File:474px-Ideogram human chromosome X.svg.png|500px|none|thumb|https://en.wikipedia.org/wiki/File:Ideogram_human_chromosome_X.svg]] | ||
==Gross Pathology== | ==Gross Pathology== | ||
There is no charactristic findings on gross pathology for Duchenne muscular dystrophy. | There is no charactristic findings on gross [[pathology]] for Duchenne [[muscular dystrophy]]. | ||
==Microscopic Pathology== | ==Microscopic Pathology== | ||
On microscopic histopathological analysis, these findings are characteristic of Duchenne muscular dystrophy: | On microscopic histopathological analysis, these findings are characteristic of Duchenne [[muscular dystrophy]]:<ref name="Emery2002">{{cite journal|last1=Emery|first1=Alan EH|title=The muscular dystrophies|journal=The Lancet|volume=359|issue=9307|year=2002|pages=687–695|issn=01406736|doi=10.1016/S0140-6736(02)07815-7}}</ref><ref name="PearceJohnsen1981">{{cite journal|last1=Pearce|first1=PH|last2=Johnsen|first2=RD|last3=Wysocki|first3=SJ|last4=Kakulas|first4=BA|title=MUSCLE LIPIDS IN DUCHENNE MUSCULAR DYSTROPHY|journal=Australian Journal of Experimental Biology and Medical Science|volume=59|issue=1|year=1981|pages=77–90|issn=0004945X|doi=10.1038/icb.1981.4}}</ref> | ||
* Replacement of muscle by fat and connective tissue | |||
* Muscle degeneration | * Replacement of [[muscle]] by [[fat]] and [[connective tissue]] | ||
* Muscle regeneration | * [[Muscle]] [[degeneration]] | ||
* Opaque hypertrophic fibers | * [[Muscle]] [[regeneration]] | ||
* Opaque [[hypertrophic]] fibers | |||
[[File:Duchenne-muscular-dystrophy-2-638.jpg|500px|none|thumb|Histopathology of gastrocnemius muscle from patient who died of pseudohypertrophic muscular dystrophy, Duchenne type. Cross section of muscle shows extensive replacement of muscle fibers by adipose cells|https://commons.wikimedia.org/wiki/File:Duchenne-muscular-dystrophy.jpg]] | [[File:Duchenne-muscular-dystrophy-2-638.jpg|500px|none|thumb|Histopathology of gastrocnemius muscle from patient who died of pseudohypertrophic muscular dystrophy, Duchenne type. Cross section of muscle shows extensive replacement of muscle fibers by adipose cells|https://commons.wikimedia.org/wiki/File:Duchenne-muscular-dystrophy.jpg]] | ||
[[File:Dys1 Dystrophinopathy carrier.jpg|500px|none|thumb|https://librepathology.org/wiki/File:Dys1_Dystrophinopathy_carrier.jpg]] | [[File:Dys1 Dystrophinopathy carrier.jpg|500px|none|thumb|https://librepathology.org/wiki/File:Dys1_Dystrophinopathy_carrier.jpg]] | ||
Latest revision as of 14:04, 29 May 2019
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Duchenne muscular dystrophy Microchapters |
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Differentiating Duchenne muscular dystrophy from other Diseases |
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Duchenne muscular dystrophy pathophysiology On the Web |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.
Overview
It is understood that Duchenne muscular dystrophy is the result of genetic mutation of dystrophin gene located on X-chromosome. Duchenne muscular dystrophy arises from muscle cells, which are involved in muscular contraction. Dystrophin protein is a part of the protein complex named dystrophin-associated protein complex (DAPC) which acts as an anchor that connect the intracellular cytoskeleton proteins such as α-dystrobrevin, syncoilin, synemin, sarcoglycan, dystroglycan, and sarcospan to the extracellular matrix. On microscopic histopathological analysis, replacement of muscle by fat and connective tissue, muscle degeneration, muscle regeneration, and opaque hypertrophic fibers are characteristic findings of Duchenne muscular dystrophy.
Pathophysiology
Physiology
The normal physiology of dystrophin protein can be understood as follows:[1][2]
- Dystrophin protein is a part of the protein complex named dystrophin-associated protein complex (DAPC) which acts as an anchor that connect the intracellular cytoskeleton proteins such as α-dystrobrevin, syncoilin, synemin, sarcoglycan, dystroglycan, and sarcospan to the extracellular matrix.
- This protein guaranties muscle strength and integrity.
- The absence of this protein or misfolded protein leads to decreased strength, increased instability, and deformity of sarcolemma.
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Pathogenesis
- It is understood that Duchenne muscular dystrophy is the result of genetic mutation of dystrophin gene located on X-chromosome.
- Duchenne muscular dystrophy arises from muscle cells, which are involved in muscular contraction.
- Duchenne muscular dystrophy is caused by a mutation of the dystrophin gene whose protein product is responsible for the connection of muscle fibres to the extracellular matrix through a protein complex containing many subunits.
- The absence of dystrophin permits excess calcium to penetrate the sarcolemma (cell membrane).
- In a complex cascading process involving several pathways, the excess calcium causes the creation of more reactive oxygen species than the cell's oxide-scavenging enzymes can effectively process.
- This creates oxidative stress within the cell which damages the sarcolemma and allows more entry points for calcium, and ultimately resulting in the death of the cell.
- Muscle fibres undergo necrosis and are ultimately replaced with adipose and connective tissue.
Genetics
- Duchenne muscular dystrophy is transmitted in X-link recessive pattern.[3][4][5]
- Gene involved in the pathogenesis of Duchenne muscular dystrophy is Xp21 gene, which encodes the protein dystrophin.
- The development of Duchenne muscular dystrophy is the result of multiple genetic mutations such as:
- Single gene defect
- 1/3 New mutation
- 2/3 X-link recessive inheritance
- Xp21.2 region
- Absent dystrophin
- Single gene defect
- In Duchenne muscular dystrophy, the dystrophin protein is absent.
- Male children, who have an XY chromosome pair, receive one of their mother's two X chromosomes and their father's Y chromosome.
- Women DMD carriers who have an abnormal X chromosome have a one-in-two chance of passing that abnormality on to their male children.
- Unlike most female children, a male child with an inherited defective Xp21 gene does not have a second X chromosome to provide correct genetic instructions, and the disease manifests.
- The sons of carrier females each have a 50% chance of having the disease, and the daughters each have a 50% chance of being carriers.
- Daughters of men with Duchenne will always be carriers, since they will inherit an affected X chromosome from their father.
- Some females will also have very mild degrees of muscular dystrophy, and this is known as being a manifesting carrier.[6]
- In one-third of the cases, the disease is a result of an unspontaneous or new mutation.
- Prenatal testing, such as amniocentesis, for pregnancies at risk is possible if the DMD disease-causing mutation has been identified in a family member or if informative linked markers have been identified.[7]
- The dystrophin gene contains 24 regions of 109 amino acids that are similar but not exact, making it susceptible to misalignment at the meiotic synapse, which can lead to frameshift mutations and an untranslatable gene.
- This can happen with a frequency of about 1 in 10,000.
- In some female cases, DMD is caused by skewed X inactivation.
- In these cases, two copies of the X chromosome exist, but for reasons currently unknown, the flawed X chromosome manifests instead of the unflawed copy.
- In these cases, a mosaic form of DMD is seen, in which some muscle cells are completely normal while others exhibit classic DMD findings.
- The effects of a mosaic form of DMD on long-term outlook is not known.
Gross Pathology
There is no charactristic findings on gross pathology for Duchenne muscular dystrophy.
Microscopic Pathology
On microscopic histopathological analysis, these findings are characteristic of Duchenne muscular dystrophy:[8][9]
- Replacement of muscle by fat and connective tissue
- Muscle degeneration
- Muscle regeneration
- Opaque hypertrophic fibers
References
- ↑ Péréon, Y.; Mercier, S.; Magot, A. (2015). "Physiopathologie de la dystrophie musculaire de Duchenne". Archives de Pédiatrie. 22 (12): 12S18–12S23. doi:10.1016/S0929-693X(16)30004-5. ISSN 0929-693X.
- ↑ Blake, Derek J.; Weir, Andrew; Newey, Sarah E.; Davies, Kay E. (2002). "Function and Genetics of Dystrophin and Dystrophin-Related Proteins in Muscle". Physiological Reviews. 82 (2): 291–329. doi:10.1152/physrev.00028.2001. ISSN 0031-9333.
- ↑ Towbin, J A; Hejtmancik, J F; Brink, P; Gelb, B; Zhu, X M; Chamberlain, J S; McCabe, E R; Swift, M (1993). "X-linked dilated cardiomyopathy. Molecular genetic evidence of linkage to the Duchenne muscular dystrophy (dystrophin) gene at the Xp21 locus". Circulation. 87 (6): 1854–1865. doi:10.1161/01.CIR.87.6.1854. ISSN 0009-7322.
- ↑ Bertelson, C J; Bartley, J A; Monaco, A P; Colletti-Feener, C; Fischbeck, K; Kunkel, L M (1986). "Localisation of Xp21 meiotic exchange points in Duchenne muscular dystrophy families". Journal of Medical Genetics. 23 (6): 531–537. doi:10.1136/jmg.23.6.531. ISSN 1468-6244.
- ↑ Lindenbaum, R H; Clarke, G; Patel, C; Moncrieff, M; Hughes, J T (1979). "Muscular dystrophy in an X; 1 translocation female suggests that Duchenne locus is on X chromosome short arm". Journal of Medical Genetics. 16 (5): 389–392. doi:10.1136/jmg.16.5.389. ISSN 1468-6244.
- ↑ Moser, H.; Emery, A. E. H. (2008). "The manifesting carrier in Duchenne muscular dystrophy". Clinical Genetics. 5 (4): 271–284. doi:10.1111/j.1399-0004.1974.tb01694.x. ISSN 0009-9163.
- ↑ Mahoney, Maurice J.; Haseltine, Florence P.; Hobbins, John C.; Banker, Betty Q.; Caskey, C. Thomas; Golbus, Mitchell S. (1977). "Prenatal Diagnosis of Duchenne's Muscular Dystrophy". New England Journal of Medicine. 297 (18): 968–973. doi:10.1056/NEJM197711032971803. ISSN 0028-4793.
- ↑ Emery, Alan EH (2002). "The muscular dystrophies". The Lancet. 359 (9307): 687–695. doi:10.1016/S0140-6736(02)07815-7. ISSN 0140-6736.
- ↑ Pearce, PH; Johnsen, RD; Wysocki, SJ; Kakulas, BA (1981). "MUSCLE LIPIDS IN DUCHENNE MUSCULAR DYSTROPHY". Australian Journal of Experimental Biology and Medical Science. 59 (1): 77–90. doi:10.1038/icb.1981.4. ISSN 0004-945X.