M.P.4.15 Adipose triglyceride lipase gene (PNPLA2) mutations in patients with myopathy related to neutral lipid storage disease

Abstracts / Neuromuscular Disorders 17 (2007) 764–900 southern Italy. The diagnosis was made by means of clinical and pathological features. Peripheral blood smear was performed in all cases. Liver biopsy was performed in six patients and muscle biopsy in five. Molecular analysis of the ABHD5 gene revealed two previously described nonsense mutations and three new molecular defects, a nonsense mutation, a splice-site mutation, and a single-base pair deletion. This first genetic study of Italian patients with Chanarin-Dorfman syndrome expands the spectrum of mutations in the ABHD5 gene, confirms the allelic heterogeneity of the disease, and strengthens the notion that CD is prevalent in the Mediterranean basin. doi:10.1016/j.nmd.2007.06.338

M.P.4.13 PNPLA2 mutations in two families with neutral lipid storage myopathy Casali, C. 1,*; Campagna, F. 2; Nanni, L. 2; Pennisi, E. 3; Michailidis, C. 4; Bruno, C. 5; Hirano, M. 6; Pierelli, F. 7; Arca, M. 2; Di Mauro, S. 6 1 Polo Pontino, Neurology & ORL, Rome, Italy; 2 Rome La Sapienza University, Dipartimento di Clinica e Terapia Medica, Rome, Italy; 3 Ospedale San Filippo Neri, Rome, Italy; 4 Polo Pontino Rome La Sapienza University, Neuro & ORL, Rome, Italy; 5 IRCCS Ospedale Giannina Gaslini, Genova, Italy; 6 Columbia University, Neurology, New York, United States; 7 Polo Pontino Rome La Sapienza University, Neurology & ORL, Rome, Italy Neutral lipid storage disease (NLSD) comprises a heterogeneous group of autosomal recessive disorders characterized by systemic accumulation of triglycerides in cytoplasmic droplets, and includes the Chanarin-Dorfman syndrome (CDS), which is characterized by prominent ichtyosis, myopathy and hepatomegaly. CDS is due to mutations in the ABHD5 (also known as CGI-58) gene. Recently, patients with NLSD and prominent myopathy but without ichtyosis have been found to harbour mutations in the adipose triglyceride lipase gene (PNPLA2, also known as ATGL) gene, which is also involved in triglycerides degradation. Here, we describe the clinical and genetic findings in three patients. The first patient is a 44-year old woman of Iranian origin, whose healthy parents are first cousins, and who had exercise intolerance since childhood. After age 30, she developed progressive proximal weakness in the upper and lower limb girdles and elevated CK levels. Muscle biopsy showed striking neutral lipid accumulation. Peripheral blood leukocytes also showed cytoplasmic lipid droplets (Jordans’ anomaly). The other patients are two brothers, aged 40 and 35, whose parents are not consanguineous. They presented with early fatigability and proximal limb girdle weakness after age 30, elevated CK levels, Jordans’ anomaly and striking neutral lipid accumulation in muscle. Mutation analysis was performed using genomic DNA. We investigated the 10 exons and their intron-exon junctions of the PNPLA2/ATGL gene by direct sequencing with the fluorescent dideoxy termination method on an ABI 310 automated sequencer. We identified mutations in the PNPLA2 gene in both families. Both mutations were in exon 5 and lead to a truncated ATGL protein but an intact patatin domain containing the active site. doi:10.1016/j.nmd.2007.06.339

M.P.4.14 Clinicopathological features of Japanese patients with PNPLA2 gene mutation Ohkuma, A. *; Hayashi, Y.; Noguchi, S.; Nonaka, I.; Nishino, I. National Institute of Neuroscience, NCNP, Department of Neuromuscular Research, Tokyo, Japan Lipid storage myopathy (LSM) comprises a heterogenous group of disorders characterized by cytoplasmic accumulation of triglycerides droplets

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in muscle fibers and other cells. Chanarin-Dorfman syndrome (CDS) has been known as a rare autosomal recessive form of LSM with ichthyosis. CDS is caused by mutations in CGI-58, a gene that encodes for the co-activator of PNPLA2. Recently Fischer et al. have reported a LSM similar to CDS without ichthyosis by mutation in PNPLA2. To identify mutations in PNPLA2 among patients of LSM in Japan. Thirty seven patients from our muscle repository within the past 28 years diagnosed to have LSM were studied. We sequenced all nine coding exons of PNPLA2 (Gene ID: 57104) together with their flanking introns using genomic DNA from patients. Two patients who are apparently unrelated, had a homozygous mutation with 4 base pair duplication (c.447_448insCCTC) in exon 4 leading to a premature stop codon at amino acid position 178. One was a 27year-old man who showed distal dominant muscle weakness, atrophy and severe dilated cardiomyopathy. The other was a 35-year-old woman who had proximal dominant muscle weakness and left ventricular hypertrophy by ECG. On muscle pathology, both patients showed numerous lipid droplets predominantly in type 1 fibers in addition to variation in fiber size. Interestingly, rimmed vacuoles (RVs) were seen in both patients. We identified the first Japanese patients with a homozygous PNPLA2 mutation. Clinically, they showed variable degrees of cardiac abnormality and different patterns of skeletal muscle involvements. To the best of our knowledge, this is the first report of the presence of RVs in skeletal muscles of LSM patients. Pathologically, PNPLA2 mutation may be characterized by the presence of RVs in addition to lipid storage. doi:10.1016/j.nmd.2007.06.340

M.P.4.15 Adipose triglyceride lipase gene (PNPLA2) mutations in patients with myopathy related to neutral lipid storage disease Laforeˆt, P. 1,*; Mussini, J. 2; Lacroix, C. 3; Hammouda, E. 4; Hu, Y. Chau 1; Lefe`vre, C. 5; Salvayre, R. 6; Eymard, B. 1; Fischer, J. 5 1 Institut de Myologie, Hoˆpital Pitie´-Salpeˆtrie`re, AP-HP, Paris, France; 2 Department of Internal Medicine, CHU de Nantes, Nantes, France; 3 Service de Neurologie, CHU de Biceˆtre, Kremlin-Biceˆtre, France; 4 AFM, Genethon, Evry, France; 5 Centre National de Ge´notypage, Evry, France; 6 INSERM U-466, CHU Rangueil, Toulouse, France Background: Neutral lipid storage disease (NLSD) comprises a heterogeneous group of autosomal recessive disorders characterized by accumulation of triglycerides in cytoplasmic droplets. Chanarin-Dorfman syndrome (CDS) is defined as an NLSD with ichthyosis, mild myopathy and hepatomegaly, due to mutations in CGI-58/ABHD5. Some patients with NLSD present atypical CDS features with myopathy, but without ichthyosis and without mutation in CGI-58/ABHD5. Objective: We report two adult patients with NLSD and myopathy, and mutations in both alleles of adipose triglyceride lipase gene (PNPLA2 or ATGL). Methods: Diagnosis of NLSD is based on the presence of massive muscle lipidosis, normal serum carnitine levels and detection of lipid containing cytoplasmic droplets in leukocytes (Jordan’s anomaly). Because no mutation was detected in CGI-58, the ATGL/PNPLA2 gene was sequenced because its major role in the degradation of cytoplasmic triglycerides made it a good candidate gene. Results: Patient 1 presented delay in walking, and was never able to run. Chronic pancreatitis and hepatomegaly were discovered at the age of 23 years. Type I diabetes occurred at age 26. She presented a moderate proximal limb-girdle weakness. A cardiomyopathy appeared at age 33, complicated by cerebral embolism leading to death at age 34. Patient 2, is a 37-year-old woman with Algerian ancestry. At the age of 27 years she presented a subacute right foot drop and right hand weakness. Clinical examination at age 28 revealed severe distal lower limbs weakness predominating in the right leg. An asymmetrical upper limbs weakness was also observed, involving the right biceps brachii, radialis and extensor digitorum. There was neither hepatomegaly nor cardiomyopathy, and she is still ambulatory. Conclusion: ATGL/PNPLA2 mutations should be investigated in myopathies with progressive limb muscle weak-

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ness associated with muscle lipidosis, lipid vacuoles in leukocytes and normal carnitine levels. doi:10.1016/j.nmd.2007.06.341

M.P.4.16 Atypical clinical presentation of an infant with short chain acyl-CoA dehydrogenase (SCAD) deficiency Fequiere, P. 1,*; Wong, B. 1; Miles, L. 2; Gregersen, N. 3; Wong, L. 4; Hopkin, R. 5 1 Cincinnati Children’s Hospital Medical Center, Division of Neurology, Cincinnati, OH, United States; 2 Cincinnati Children’s Hospital Medical Center, Division of Pathology, Cincinnati, OH, United States; 3 Research Unit for Molecular Medicine, Department of Molecular Medicine, Brendstrupgaardvej, Denmark; 4 Baylor College of Medicine, Department of Molecular and Human Genetics, Baylor, TX, United States; 5 Cincinnati Children’s Hospital Medical Center, Division of Genetics, Cincinnati, OH, United States Short chain acyl-CoA dehydrogenase (SCAD) deficiency is a rare condition which typically presents with seizures, neuropathy, developmental delay, myopathy, vomiting. We describe an infant with unusual clinical presentation related to SCAD deficiency. A female infant with in utero polyhydramnios, growth retardation, born full term presented at birth with generalized hypotonia, severe dysphagia, osteopenia, dysmorphic features. She developed overtime a mixed apnea with oxygen dependence, bilateral optic atrophy, retinal degeneration, sensory hearing loss, sensory neuropathy, upper airway obstruction, right sided hydronephrosis. She died at nine months due to a respiratory infection. Her work up was pertinent for a relatively high urinary ethylmalonic acid level (36 mmol, range: 18-31) while on a low fat diet, a normal CSF lactate and was found to be homozygous for a common mutation of SCAD gene (625G > A). Two brain MRI showed progressive multifocal symmetrical signal abnormalities in the brainstem and several cystic lesions in the periventricular areas. Her muscle biopsy showed myopathic muscle fibers and her sural nerve biopsy displayed absent myelination of large nerves with focal axonal degeneration. Electron transfer complex studies on muscle were normal. Her skin fibroblasts fatty acid oxidation studies showed a markedly elevated butyrylcarnitine level (11.7 nmol/mg, range mean: 1.79). Her conjunctival biopsy for neuroaxonal dystrophy was negative. Her autopsy showed a spongiform neuroaxonal degeneration of her brain and anterior spinal cord. It also displayed bilateral frontal and temporal lobes atrophy and microcysts (0.1 cm) in the brainstem. We report a patient with a homozygous SCAD gene mutation (625G > A) with biochemical evidence for SCAD deficiency and a severe neurodegenerative phenotype consisting of facial dysmorphism, spongiform encephalopathy, bilateral optic atrophy, retinal degeneration, neuronopathy, neuropathy and myopathy. We propose that other gene modifying factors influencing the phenotype of patients with SCAD mutations are to be investigated since not all patients with this mutation have clinical signs. doi:10.1016/j.nmd.2007.06.342

M.P.4.17 Late onset multiple acyl-CoA dehydrogenase deficiency (MADD) associated with novel ETFDH mutations in two Chinese patients Pramono, Z. 1,*; Lai, P. 2; Tan, I. 3; Lim, M. 3; Seah, I. 1; Yee, W. 1 1 National Neuroscience Institute, Singapore, Singapore; 2 National University of Singapore, Singapore, Singapore; 3 Singapore General Hospital, Singapore, Singapore Multiple acyl-CoA dehydrogenase deficiency, also known as glutaric aciduria type II, is a disorder of fatty acid, amino acid, and choline

metabolism with autosomal recessive inheritance. The disorder may be due to defect(s) in the alpha- or beta-subunit of electron transfer flavoprotein (ETFA, ETFB) or ETF dehydrogenase (ETFDH). Unlike MADD with neonatal onset, late onset MADD has highly variable presentation and is more rare, with only nine cases with identified genotypes reported to date. We report two unrelated Chinese patients with late onset MADD. In Patient 1, the disease presented in adolescence with an acute episode of severe weakness and vomiting and was diagnosed as lipid storage myopathy on muscle biopsy. She responded well to empirical self medication with riboflavin. Patient 2 developed recurrent episodes of severe and life threatening weakness from age 12 years and was treated with immunosuppressive agents from onset for a diagnosis of polymyositis. When seen at age 24 years and 43 years respectively, both patients showed an organic acid profile consistent with glutaric aciduria type II on urine mass spectroscopy. Patient 2’s muscle biopsy confirmed lipid storage myopathy. Direct sequence analysis of cDNA and genomic DNA was conducted to screen for mutations in coding regions of ETFA, ETFB and ETFDH genes. No gross re-arrangement or mutation was identified in ETFA and ETFB genes in both patients. Compound heterozygous mutations, A84T mutation and exons 2–9 skipping, were detected in the ETFDH gene in Patient 1, while homozygous A84T mutation was found in Patient 2. The missense A84T mutation is predicted to change ETFDH protein polarity and hydrophobicity. These novel mutations add to 7 known ETFDH mutations associated with late onset MADD and are the first mutations identified in Chinese patients with late onset MADD. doi:10.1016/j.nmd.2007.06.343

POSTERS 21 PSYCHOSOCIAL ASPECTS IN NEUROMUSCULAR DISEASES G.P.15.01 Pilot study to determine the transition needs of adolescents and adults with Duchenne muscular dystrophy Viana, R. 1; LaDonna, K. 2,*; Koopman, W. 2; Campbell, C. 1; Schulz, V. 1; Venance, S. 2 1 London Health Sciences Centre, London, Canada; 2 London Health Sciences Centre, Clinical Neurological Sciences, London, Canada The increasing life expectancy for men living with Duchenne muscular dystrophy (DMD) necessitates a transition from pediatric to adult neuromuscular care. The aim of transition is to provide comprehensive, appropriate care in a coordinated and uninterrupted manner by meeting the developmentally appropriate needs of the individual. The evolving physical and social needs of adults living with DMD need to be addressed. The objectives of this study are to determine the needs and quality of life of individuals with DMD transitioning from the pediatric clinic to the adult Neuromuscular clinic. The information gleaned from this study will be useful in developing a comprehensive transition program. Does the introduction of a new health care team, altered social roles, and resource allocation cause stress for men transitioning from pediatric to adult care? Further, is the transition compounded by physical decline, evolving social needs, and the individual’s quality of life? Adolescents or men with DMD attending either a pediatric or adult Neuromuscular clinic, and a caregiver identified by the individual, were asked to participate. Participants completed a semi-structured, qualitative interview regarding the transition process, their current and future physical needs, social relationships and autonomy. Issues addressed include examination of services, integration and access to hospital and community programs, and physical functioning. The men also completed the Individualized Neuromuscular Quality of Life Questionnaire (InQoL). The audio-taped interviews were transcribed and analyzed by two raters to extrapolate emerging themes. The interviews were well tolerated by both the men with DMD and their caregiver. The interviews have gleaned important information about the daily