Neuropathology and Applird Neurobiology 1995. 21, 68-73

Oculopharyngeal muscular dystrophy: clinical and morphological follow-up study reveals mitochondrial alterations and unique nuclear inclusions in a severe autosomal recessive type J. M. Schroder, B. Krabbe and J. Weis

Institute of Neuropathology. Technical University, Aarhen, Germany

J. M. Schroder, B. ECrabbe and J. Weis (1995) Neuropathology and Applied Neurobiology 21, 68-73 Oculopharyngeal muscular dystrophy: clinical and morphological follow-up study reveals mitochondrial alterations and unique nuclear inclusions in a severe autosomal recessive type

Oculopharyngeal muscular dystrophy (OPMD) is usually a late onset, autosomal dominant dystrophy that affects extraocular eye muscles, pharyngeal muscles, and the trunk and limb musculature. In the present presumably recessively inherited case, with a clinical history of oculopharyngeal myopathy and distal weakness, paracrystalline mitochondrial inclusions and unique nuclear inclusions were found. In a biopsy obtained from the erector spinae muscle, marked muscle fibre atrophy and hypertrophy, occasional muscle fibre necrosis, and considerable fibrosis of the endomysium were noted. Similar signs of a chronic myopathy could already be detected in a biopsy from the anterior tibia1 muscle that had been obtained 10 years before. In both muscles,

nuclear inclusions were seen in numerous severely affected, atrophic muscle fibres. These inclusions con- sisted of straight or helically wound 2 4 nm filaments. The outer diameter of the double helix was 12-1 5 nm and the periodicity of its repeats was about 15 rim, The filaments were often accumulated in clusters with a paracrystalline arrangement. No nuclear inclusions con- sisting of 8.5 nm tubular filaments, typically found in cases of OPMD, were detected. In addition, paracrystal- line inclusions were present in a large number of mito- chondria in several muscle fibres of the erector spinae muscle indicating that mitochondria could be primarily involved in the disease.

Keywords: oculopharyngeal distal muscular dystrophy, OPMD, nuclear inclusions, paracrystalline inclusions

Introduction reported [16, 32, 351. Morphologically, both myopathic

Oculopharyngeal muscular dystrophy (OPMD) is an autosomal dominant disease of late onset characterized by slowly progressive atrophy of extraocular muscles and dysphagia 143, 451. Gradually, the trunk and limb muscles become involved. In some Japanese cases, the distal muscles are affected most severely [14, 231, in others, the distribution of the weakness is proximal [ 2 ] . Rarely, involvement of the motor nerves has been

and neurogenic changes in the affected muscles are found. Filamentous intranuclear inclusions are a char- acteristic feature of the disease. These inclusions are typically found in muscle fibre nuclei [ 3 , 7. 21, 22, 441. They are tubulofilamentous structures with an outer diameter of 8.5 nm and an inner space of about 3 nm [42]. They clearly differ from tubulofilamentous struc- tures seen in ‘inclusion body myopathy’ (IBM) which measure 16-18 nm in diameter [4, 61. IBM is considered

Correspondence: IJniv.-Prof. Dr J. M. Schroder. Institut fur Neuro- pathologie der Mcdizinischen Fakultat an der Khcinisch-Wcslfalischen

the most frequent myopathy at the age of than 5 5

Technischen Ho&s&& Aachen. Pauweksstr. 3 0 , D- j2057 Aa&en, years fi9i. In affected sarcoplasmic Germany. sions are found, some of which are filamentous and

Pararrystallinr nuclear inclusions in OPMD 69

immunoreactive with ubiquitin, P-amyloid, and P- amyloid precursor protein antibodies [l, 191. Often inflammatory cell infiltrates are present, but a non- inflammatory IBM-like disorder with usually autosomal recessive (see [19]) or dominant inheritance [20, 281 has also been reported.

Similar intranuclear inclusion bodies as seen in IBM have been found in neurons and in medullary cells of the adrenal glands [41] in cases of systemic neuronal intra- nuclear hyaline inclusion disease. In this disorder, hya- line inclusions are found in nuclei of various subsets of neurons [15, 17, 24, 27, 29, 39. 40, 411 as well as in astrocytes, Schwann cells, cells of the pituitary gland, and muscle fibres [12] associated with a wide spectrum of neurological disorders including mental deterioration, paresis. ataxia, dysphagia, dysarthria, and dysfunction of the extraocular eye muscles, in some cases mimicking systems degeneration like Friedreich’s ataxia [ 391. These various filamentous nuclear inclusions differ from those in granular nuclear inclusion body disease [ 3 71.

In rare cases of OPMD, mitochondria1 abnormalities have been detected [9. 13, 18, 30, 311. We here report a case of familial oculopharyngeal distal myopathy associ- ated with distal myopathy that showed numerous unusual intranuclear inclusions with straight or twisted filaments as well as paracrystalline inclusions of the common type in mitochondria of muscle fibres.

Case report

At the age of 40 years, this female patient f ist noted weakness of the muscles of the extremities, preferentially of the hand and calf muscles, which was slowly progres- sive. Simultaneously, ptosis and difficulties in swallowing developed. Repeated electroneurographic examinations had been normal. Electromyography of the biceps brachii muscle revealed low-amplitude motor unit potentials of short duration mixed with occasional enlarged motor unit potentials.

The parents and the grandparents of the patient had reportedly not shown any signs of neuromuscular dis- ease. The mother of the patient had been married twice. The three children from her first marriage had no neuromuscular disease. During her second marriage, she had five children, all of whom were female. Two sisters of the patient had a progressive distal muscular atrophy associated with difficulties in swallowing. The disease first became apparent around the menopause in both of

these sisters and they both died of respiratory failure approximately 20 years later. No biopsy or autopsy was performed.

The two remaining sisters of the patient were not affected by the disease. Each of the five sisters had given birth to at least one child. All these children, including the 40-year-old son of the present patient, have as yet not shown any signs of neuromuscular disease.

Muscle biopsies

Segments of the erector spinae muscle were frozen in liquid nitrogen for histochemical studies, fixed in formal- dehyde for paraffin embedding, or fixed in 6% glutaral- dehyde in 0.1 M Ssrensen’s buffer for embedding in epoxy resin. Standard histological techniques were used to further process the material [36]. The results could be compared to a biopsy specimen of the anterior tibial muscle, which had been obtained 10 years before the present biopsy specimen while the patient was in a different hospital. The latter biopsy had also been examined by us using the same techniques.

Light microscopically, severe muscle fibre atrophy with numerous rounded or angular atrophic muscle fibres, sometimes in a grouped neurogenic pattern, and cross-sectional diameters of less than 20 pm, as well as hypertrophic muscle fibres with cross-sectional diam- eters of up to 160 pm were seen in the anterior tibial muscle. Numerous muscle fibres showed centrally dis- placed nuclei and severe myofibrillar abnormalities There was prominent proliferation of fat cells and con- nective tissue. Several muscle fibre nuclei showed promi- nent nucleoli. In the erector spinae muscle, muscle fibres of normal size were more frequent than in the anterior tibial muscle biopsy obtained 10 years earlier. Still, a large number of atrophic as well as hypertrophic muscle fibres were found. Histochemically. numerous muscle fibres showed slightly increased subsarcolemmal NADH activity. Ragged-red fibres, however, were absent.

Electron microscopic analysis revealed nuclear in- clusions consisting of tangles of straight or - more often - helically wound filaments that had accumulated in a pattern reminiscent of paracrystalline structures in about 10% of the nuclei in muscle fibres of both biopsies (Figure la-d). The diameters of the individual filaments forming the helices varied between 2 and 4 nm. The outer diameter of the double helix measured 12-14nm, and the period of its repeats was about

70 J. M. Schroder et al.

Paracrystalline nuclear inclusions in OPMD 71

1 5 nm. Occasionally a small intranuclear cluster of loosely arranged 6 nm filaments, presumably actin fila- ments, was observed. In addition, paracrystalline inclu- sions were found in mitochondria of less than 5010 of the muscle fibres of the truncal biopsy (Figure le). In several muscle fibres, myofibrillar anomalies and small accumu- lations of myelin-like material with minor vacuole for- mation (‘rimmed vacuoles’) were present. Very rarely, 16-18 nm tubulo-filamentous inclusions were found in the adjacent sarcoplasm.

Discussion

In the present case, the typical clinical features of OPMD, late onset predominantly distal muscular dystrophy associated with ptosis and dysphagia, were observed. However, the clinical course was unusually severe and the inheritance pattern was not suggestive of an auto- soma1 dominant but of a recessive trait. Ultrastructural examination disclosed prominent paracrystalline nuclear inclusion bodies that have thus far not been reported. and occasional mitochondrial inclusions.

Recently, mitochondrial abnormalities have been dem- onstrated in a family of Bukhara Jews with the typical history of OPMD [30]. In the initial report, intranuclear filamentous inclusions were not described, thus support- ing the conclusions of other studies [9, 18, 261 on OPMD patients with marked abnormalities of muscle fibre mito- chondria, but no intranuclear inclusions. These mito- chondrial alterations were similar to the abnormalities found in chronic progressive external ophthalmoplegia, an acknowledged mitochondrial disease [2 51. Subse- quently, however, a new cluster of familial OPMD among Bukhara Jews with typical filamentous intranuclear inclusions was described [ 31. Revision of the specimens of the above mentioned case of Pauzner et al. [30] disclosed diffuse intranuclear filamentous inclusions in muscle fibres that had been overlooked initially [ 3 3 ] . The mito- chondrial abnormalities were considered unspecific and age-related as they might also be in the present case.

It is important to emphasize that the intranuclear filamentous inclusions in muscle fibres of the present case differ from those in neuronal inclusion body disease (for review see [12]), in cases of sporadic or familial inclusion body myositis (see Introduction), in infantile polymyositis [5], 2,4-D intoxication in rats and guinea pigs [lo], and in dominantly inherited OPMD. The inclusions in the latter disease appear to be characteristic in that they show a constant morphology. They were described to be tubular filaments of about 8.5 nm outer and 3 nm inner diameter arranged in tangles or pali- sades [42]. The present case is unusual because most nuclear inclusions, especially the ones found in the erector spinae muscle, showed a dense, paracrystalline arrangement of unique straight or helically twisted fila- ments with a diameter of 2 4 nm only. Both the tubular 8.5 nm filaments of typical OPMD cases and the 2 4 nm helically wound filaments of the present case are clearly different from the 16-18 nm tubulofilamentous struc- tures of IBM which have also been noted in myotonic dystrophy [ 111, OPMD 1381 and other diseases. In muscle fibres from OPMD patients with typical 8.5 nm intra- nuclear filaments, accumulations of 16-1 8 nm tubular filaments were observed in the sarcoplasm [8, 461. These filaments were immunoreactive with anti-ubiquitin [ 191, j3-amyloid precursor protein, and cathepsin B and D antibodies [46]. The nuclear inclusions in the present case are reminiscent of the filamentous nuclear inclusion bodies described recently in autosomal recessive IBM (‘vacuolar myopathy sparing the quadriceps’ [ 341). However, a paracrystalline arrangement of the filaments - as found in the present case - was not noted, and the type of filaments was not defined, suggest- ing that the present myopathy is a separate entity.

Acknowledgements

The authors wish to thank Mrs I. Taraschewski, Mrs H. Mader, Mrs A. Knischewski and Mrs W. Heil for techni- cal and photographic assistance, and Mrs I. Genenger for secretarial help.

Figure 1. Electron microscopic features of the erector spinae musclr. hiopsy obtained 10 years after the anterior tihial muscle biopsy. a. By electron microscopy. inclusion bodies (arrowheads) are apparent in four nuclei of this atrophic muscle fihre. An innervated neuromuscular junction is marked by an arrow. x 11 000. b. At higher magnification. one of the inclusions consists of helically wound double filaments (arrowheads). x 9 3 000. c . Another intranuclcar inclusion shows a reclangular. paracrystalline arrangcinenl of helical fibrils. x 60 000. d. This inclusion consists of thin filaments at the margins and helically wound fibrils in the centre. x 47 000. e. Suhsarcolemmal muscle fihre mitochondria show paracrystallinc inclusions (arrowheads). x 12 000.

72 1. M. Schroder et al.

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Received 16 M a y 1994 Accepted after revision 13 September 1994