Patients with DM1 can be divided into four main categories, each presenting specific clinical features and management problems: congenital, childhood-onset, adult-onset, and late-onset/asymptomatic (PMID:24803843).
Myotonic dystrophy is an autosomal dominant disorder characterized mainly by myotonia, muscular dystrophy, cataracts, hypogonadism, frontal balding, and ECG changes. The genetic defect in DM1 results from an amplified trinucleotide repeat in the 3-prime untranslated region of a ... Myotonic dystrophy is an autosomal dominant disorder characterized mainly by myotonia, muscular dystrophy, cataracts, hypogonadism, frontal balding, and ECG changes. The genetic defect in DM1 results from an amplified trinucleotide repeat in the 3-prime untranslated region of a protein kinase gene. Disease severity varies with the number of repeats: normal individuals have 5 to 37 repeats, mildly affected persons have 50 to 150 repeats, patients with classic DM have 100 to 1,000 repeats, and those with congenital onset can have more than 2,000 repeats. The disorder shows genetic anticipation, with expansion of the repeat number dependent on the sex of the transmitting parent. Alleles of 40 to 80 repeats are usually expanded when transmitted by males, whereas only alleles longer than 80 repeats tend to expand in maternal transmissions. Repeat contraction events occur 4.2 to 6.4% of the time (Musova et al., 2009). - Genetic Heterogeneity of Myotonic Dystrophy See also myotonic dystrophy-2 (DM2; 602668), which is caused by mutation in the ZNF9 gene (116955) on chromosome 3q.
In classic adult-onset cases, clinical diagnosis is straightforward with demonstration of progressive distal and bulbar dystrophy in the presence of myotonia, with frontal balding, and cataracts. Confirmatory evidence is provided by demonstration of depressed IgG and elevated CPK ... In classic adult-onset cases, clinical diagnosis is straightforward with demonstration of progressive distal and bulbar dystrophy in the presence of myotonia, with frontal balding, and cataracts. Confirmatory evidence is provided by demonstration of depressed IgG and elevated CPK in the serum. Clinical diagnosis can be difficult in mild cases, where cataracts may be the only manifestation (Bundey et al., 1970). Direct analysis of the size of the CTG repeat by Southern blotting In studies of an extensively affected Labrador kindred, Webb et al. (1978) concluded that lens opacities are not a reliable diagnostic sign. Many younger affected persons, including one in his 20s, did not have lens opacities despite clear muscular involvement. On the other hand, Ashizawa et al. (1992) concluded that bilateral iridescent and posterior cortical lens opacities are highly specific for DM and are useful for establishing the clinical diagnosis. The sensitivity of these 2 features was found to be 46.7% and 50.0%, respectively, in their series, while their specificities were 100% in both cases. Direct analysis of the size of the CTG repeat by Southern blotting permits DNA diagnosis. Normal individuals have 5 to 37 CTG repeats, whereas patients have from more than 50 to several thousand CTG repeats in peripheral leukocytes (see review by Pizzuti et al., 1993). Reardon et al. (1992) described a 5-year experience in providing presymptomatic and prenatal molecular diagnostic services based on the linkage principle using closely linked markers in 161 families. Only 10 analyses out of 235 proved uninformative, but a further 5 requests (1.9%) could not be reported because of uncertainty in clinical status. Seven of 81 (8.6%) patients considered to be at low risk on clinical grounds were found to be at high risk of carrying the gene. Reardon et al. (1992) emphasized that careful clinical examination and appropriate investigations of nonmolecular nature remain a cornerstone of diagnosis.
In adult-onset DM1, symptoms typically become evident in middle life, but signs can be detectable in the second decade. Bundey et al. (1970) found that the most useful method for identifying subclinical ... - ADULT-ONSET MYOTONIC DYSTROPHY In adult-onset DM1, symptoms typically become evident in middle life, but signs can be detectable in the second decade. Bundey et al. (1970) found that the most useful method for identifying subclinical cases is slit-lamp examination for lens changes, followed by electromyography for myotonic discharges, and then by measurement of immunoglobulins. Harper (1989) provided a monograph on myotonic dystrophy that has been updated regularly. Unlike the other muscular dystrophies, DM initially involves the distal muscles of the extremities and only later affects the proximal musculature. In addition, there is early involvement of the muscles of the head and neck. Involvement of the extraocular muscles produces ptosis, weakness of eyelid closure, and limitation of extraocular movements. Atrophy of masseters, sternocleidomastoids, and the temporalis muscle produces a characteristic haggard appearance. Bosma and Brodie (1969) demonstrated both myotonia and weakness in patients with swallowing and speech disability. Myotonia, delayed muscular relaxation following contraction, is most frequently apparent in the tongue, forearm, and hand. Myotonia is rarely as severe as in myotonia congenita and tends to be less apparent as weakness progresses. Many of the muscle biopsy changes are nonspecific. Most commonly there are central nuclei and ring fibers. Necrosis, regeneration, and increase of collagen are never as severe as in Duchenne muscular dystrophy. In 70% of patients there is hypotrophy of type I muscle fibers; less commonly there are markedly atrophic fibers (Casanova and Jerusalem, 1979). In many cases there are target fibers, suggesting neurogenic dysfunction, but intramuscular nerves appear histologically normal (Drachman and Fambrough, 1976). Ultrastructural studies show dilatation of T tubules or sarcoplasmic reticulum, whose contents may be unusually dense (Fardeau et al., 1965). In some cases the surface membrane may be irregular, with reduplication of basal lamina. - Neurologic Features From a series of neurophysiologic investigations of 24 patients with myotonic dystrophy, Jamal et al. (1986) concluded that there was unequivocal evidence of widespread nervous system dysfunction. In many patients there was significant involvement of peripheral large diameter motor and sensory fibers and of small diameter sensory fibers peripherally and/or centrally. The authors stated that 'the concept of myotonic dystrophy as a pure myopathy can no longer be sustained.' This conclusion is supported by the findings in the family reported by Spaans et al. (1986). Thirteen members of a large family presented with a hereditary motor and sensory neuropathy in a dominant pedigree pattern. The mean motor conduction velocities for the median and peroneal nerves in the affected individuals were 62% and 56%, respectively, of those of the unaffected relatives. Eight of the 13 affected members also showed more or less prominent signs of myotonic dystrophy. There was no case of myotonic dystrophy alone. Turnpenny et al. (1994) found that IQ in myotonic dystrophy declined as the age of onset of signs and symptoms decreased and as the size of the CTG expansion increased. The correlation appeared to be more linear with age of onset. Censori et al. (1994) carried out a prospective case-control study of 25 patients with myotonic dystrophy using magnetic resonance imaging (MRI) of the brain. They found that 84% of myotonic dystrophy patients showed white matter hyperintense lesions, compared with 16% of controls. Most of these lesions involved all cerebral lobes without hemispheric prevalence, but 28% of the myotonic dystrophy patients also showed particular white matter hyperintense lesions at their temporal poles. Myotonic patients also showed significantly more cortical atrophy than did controls. However, there was no relationship between atrophy or white matter hyperintense lesions and age, disease duration, or neuropsychologic impairment. Damian et al. (1994) found that amplification of the CTG repeat in leukocytes strongly correlated with cognitive test deficits when the expansion length exceeded over 1,000 trinucleotides. MRI lesions were associated with impaired psychometric performance, but the MRI findings of subcortical white matter lesions correlated only very weakly with the molecular findings. Miaux et al. (1997) found that 9 (70%) of 13 patients with a mild form of adult myotonic dystrophy had T2-weighted signal abnormalities on brain MRI. Four patients (30%) had lesions greater than 1 cm in diameter. Lesions were symmetric, occurred in the subcortical white matter, and showed a predilection for the temporal lobe. There was some evidence of cerebral atrophy in the patients overall but no difference in IQ between patients and controls. There was no correlation between number of pathologic CTG repeats and white matter lesions, and there was no correlation between intellectual impairment and white matter lesions, except in 1 patient who had a difficult birth and temporal lobe epilepsy. Three patients had marked thickening of the skull, which was associated with ossification of the falx in 2. Donahue et al. (2009) reported a 56-year-old woman with a 10-year history of myotonic dystrophy who presented with progressive lower extremity weakness. Brain MRI showed multiple discrete and confluent areas of abnormal signal intensity throughout the subcortical white matter with predominant involvement of the frontal and anterior temporal lobes. There was also diffuse thickening of the skull with ossification of the falx. Donahue et al. (2009) noted the similarity of the white matter findings with those observed in CADASIL (125310), but noted that skull abnormalities are not seen in CADASIL. In a study of 21 patients with myotonic dystrophy, Akiguchi et al. (1999) found that MRI results indicated progressive brain atrophy. Magnetic resonance spectroscopy demonstrated a significant reduction of the neuronal marker N-acetylaspartate, even in young patients in whom imaging studies were still equivocal. Delaporte (1998) found that 15 DM patients with no or minimal muscle weakness demonstrated a homogeneous personality profile characterized by avoidant, obsessive-compulsive, passive-aggressive, and schizotypic traits. Fourteen healthy control individuals and 12 patients with a mild form of muscle disease did not show the same trait homogeneity. Delaporte (1998) concluded that the personality disorders were not attributable to the adjustment to a disabling condition, but rather were primary manifestations of the genetic mutation. Modoni et al. (2004) performed detailed neuropsychologic testing of 70 patients with DM1, including 10 with congenital onset and 60 with juvenile-adult onset, who were subdivided into 4 genotypic subgroups according to number of repeat expansion. Patients with congenital onset (CTG repeats greater than 1,000) obtained the lowest scores in verbal attainment, frontal and executive functions, and general intelligence, consistent with mental retardation. Patients with 50 to 150 repeats showed age-dependent impairment in memory, frontal lobe, and temporal lobe function. Patients with 151 to 1,000 repeats showed defects only in frontal and executive tasks. Although there was a correlation between number of repeats and degree of muscle involvement for all patients, there was not a significant correlation between number of repeats and cognitive impairment, except for the congenital group. Sergeant et al. (2001) stated that neurofibrillary tangles (NFT), as described in patients with Alzheimer disease (AD; 104300), had been described in the neocortex and subcortical regions of patients with DM1. NFTs derive from pathologic aggregation of hyperphosphorylated tau (MAPT; 157140) proteins. By neuropathologic examination, Sergeant et al. (2001) identified hippocampal NFTs in 4 of 5 patients with DM1 ranging in age from 42 to 64 years. Three patients had clinical evidence of cognitive impairment or mental retardation. In some of the patients, other brain regions also had NFTs. Biochemical characterization showed overexpression of tau protein isoforms lacking exons 2 and 3, suggesting that the DMPK mutation disrupts normal MAPT isoform expression and alters the maturation of MAPT pre-mRNA. Maurage et al. (2005) identified biochemically similar NFTs in multiple brain regions of a patient with DM2; however, the patient with DM2 was mentally normal, demonstrated no cognitive decline, and died at age 71 years from a bilateral renal thrombosis. - Cardiac Features Hawley et al. (1983) suggested that the tendency to have heart block or arrhythmia with myotonic dystrophy is a familial characteristic. The implication was that there may be 2 forms of myotonic dystrophy. They studied 18 families and found heart block in 4. In a single large kindred, Tokgozoglu et al. (1995) compared the cardiac findings in 25 patients with myotonic dystrophy with age-matched normal family members. They found that the patients were more likely to have conduction abnormality (52% vs 9%), mitral valve prolapse (32% vs 9%), and wall motion abnormality (25% vs 0%). Left ventricular ejection fractions and stroke volume were reduced compared with normals. Using multivariate analysis, the number of CTG repeats (range, 69 to 1367; normal, less than 38) was the strongest predictor of abnormalities in wall motion and EKG conduction. Patients with more extensive neurologic findings had a higher incidence of wall motion and/or EKG conduction abnormalities. The authors also found that the relation of mitral valve prolapse to the size of the CTG repeat was of borderline significance. Cardiac involvement is well described in adults with myotonic dystrophy. Bu'Lock et al. (1999) undertook detailed cardiac assessment in 12 children and young adults with congenital myotonic dystrophy using control data from 137 healthy children and young adults. All patients were in sinus rhythm with a normal P wave axis. Three had first-degree heart block and 4 had a borderline P-R interval (200 ms). Four others had more complex conduction abnormalities. Three patients had mitral valve prolapse. Eleven of the 12 patients had abnormalities of 1 or more parameter of left ventricular diastolic filling. None of these patients were symptomatic. The authors commented that the prognostic implications of these findings were unclear; however, they concluded that echocardiographic assessment of left ventricular diastolic function may be a useful adjunct to electrocardiographic monitoring of patients with congenital myotonic dystrophy. Antonini et al. (2000) performed a prospective study of 50 DM1 patients without known cardiac disease at the time of enrollment. Nineteen patients developed major cardiac abnormalities during the 56-month study. No correlation was found between CTG length and frequency of EKG abnormality or type of arrhythmia. CTG length was inversely correlated with age at onset of EKG abnormality. Bassez et al. (2004) reported 11 DM1 patients under the age of 18 years who had severe cardiac involvement. Two patients died suddenly, 1 patient had cardiac arrest with successful resuscitation, and 1 asymptomatic 13-year-old girl presented with recurrent presyncope. Rhythm disturbances included atrial flutter in 4, ventricular tachycardia in 4, and atrial fibrillation in 1. Five patients had atrioventricular block necessitating pacemaker implantation. Six of 11 patients (55%) experienced arrhythmic events with vigorous exercise. Genetic analysis detected between 235 and 1,200 CTG repeats in all patients. No cardiac involvement was detected before age 10 years. Bassez et al. (2004) concluded that patients with congenital or childhood forms of DM1 may present with cardiac abnormalities and that exercise testing is a necessary evaluation in these patients. Groh et al. (2008) found that 96 of 406 patients with genetically confirmed DM1 had severe ECG abnormalities, and that these patients were older, had more CTG repeats, and had more severe muscular impairment compared to those without ECG abnormalities. After a mean follow-up period of 5.7 years, 69 patients who did not have ECG abnormalities at the start of the study had developed ECG abnormalities and 81 patients died. There were 27 sudden deaths, 32 deaths from progressive neuromuscular respiratory failure, 5 nonsudden deaths from cardiac causes, and 17 deaths from other causes. The major cause of death in the cohort was respiratory failure associated with progressive muscular weakness. A severe ECG abnormality and a clinical diagnosis of atrial tachyarrhythmia conferred relative risks for sudden death of 3.30 and 5.18, respectively. - CONGENITAL MYOTONIC DYSTROPHY Harper (1975) observed that in a small proportion of cases, myotonic dystrophy may be congenital with neonatal hypotonia, motor and mental retardation, and facial diplegia. With rare exception, it is the mother who transmits the disease. Diagnosis can be difficult if the family history is not known because muscle wasting may not be apparent, and cataracts and clinical myotonia are absent, although the latter is sometimes detectable by electromyography. Fried et al. (1975) observed that infants with neonatal myotonic dystrophy (almost always the mother is affected) have thin ribs. Talipes at birth, together with hydramnios and reduced fetal movements during pregnancy, is frequent. Respiratory difficulties are frequent and are often fatal. Those that survive the neonatal period initially follow a static course, eventually learning to walk but with significant mental retardation in 60 to 70% of cases. By age 10 they develop myotonia and in adulthood develop the additional complications described for the adult-onset disease. Roig et al. (1994) reported long-term follow-up of 18 patients diagnosed with congenital myotonic dystrophy. Three of the 18 had died, and 5 were lost to follow-up. The remaining 10 had IQs of less than 65. Universal findings were language delay, hypotonia, and delayed motor development. There was no difficulty with routine immunizations nor were there anesthetic complications observed in any of the 7 patients who underwent surgery. Rudnik-Schoneborn et al. (1998) reviewed the obstetric histories of 26 women with myotonic dystrophy who had a total of 67 gestations, comparing gestations with affected and unaffected fetuses. Of the 56 infants carried to term, 29 had or most likely had inherited the gene for DM from their affected mothers; 18 of the 29 (61%) were affected by the congenital form of DM. Perinatal loss rate was 11% and associated with congenital DM. Preterm labor was a major problem in gestations with DM-fetuses (55 vs 20%), as was polyhydramnios (21% vs none). While forceps deliveries or vacuum extractions were required in 21% of deliveries with DM-fetuses and only 5% of unaffected fetuses, the frequency of cesarean sections were similar in the 2 groups. Obstetric problems were inversely correlated with age at onset of maternal DM, while no effect of age at delivery or birth order on gestational outcome was seen. Stratton and Patterson (1993) established the molecular diagnosis of myotonic dystrophy in a fetus shown to have bilateral effusions and scalp and upper torso edema by ultrasound examination at 30 weeks' gestation. Polyhydramnios was also present. Thus, nonimmune hydrops fetalis is a manifestation of congenital myotonic dystrophy. The mother had previously unsuspected myotonic dystrophy, but she did show grasp myotonia. Her brother had a confirmed diagnosis. The DM gene showed marked expansion in her fetus. Stratton and Patterson (1993) found reports of 15 other cases of nonimmune hydrops fetalis associated with congenital myotonic dystrophy. (Robin et al. (1994) described nonimmune hydrops fetalis in association with severely impaired fetal movement, giving support to the notion that fetal hypomobility is a cause of this disorder. The hydropic infant stopped moving 8 weeks before delivery and did not move postnatally. Autopsy revealed extensive CNS destruction of unknown cause.)
Arsenault et al. (2006) examined 102 patients with DM1 carrying small CTG repeat expansions in the DMPK gene. Most patients with 50 to 99 repeats were asymptomatic except for cataracts. Patients with 100 to 200 repeats were significantly ... Arsenault et al. (2006) examined 102 patients with DM1 carrying small CTG repeat expansions in the DMPK gene. Most patients with 50 to 99 repeats were asymptomatic except for cataracts. Patients with 100 to 200 repeats were significantly more likely to have myotonia, weakness, excessive daytime sleepiness, and myotonic discharges on EMG.
Harley et al. (1992) isolated a human genomic clone that detected novel restriction fragments specific to persons with myotonic dystrophy. A 2-allele EcoRI polymorphism was seen in normal persons, ... - Identification of an Expanded Triplet Repeat Harley et al. (1992) isolated a human genomic clone that detected novel restriction fragments specific to persons with myotonic dystrophy. A 2-allele EcoRI polymorphism was seen in normal persons, but in most affected individuals one of the normal alleles was replaced by a larger fragment, which varied in length both between unrelated affected individuals and within families. The unstable nature of this region was thought to explain the characteristic variation in severity and age at onset of the disease. From a region of chromosome 19 flanked by 2 tightly linked markers, ERCC1 (126380) proximally and D19S51 distally, Buxton et al. (1992) isolated an expressed sequence that detected a DNA fragment that was larger in affected persons than in normal sibs or unaffected controls. Aslanidis et al. (1992) cloned the essential region between the above mentioned markers in a 700-kb contig formed by overlapping cosmids and yeast artificial chromosomes (YACs). The central part of the contig bridged an area of about 350 kb between 2 flanking crossover borders. This segment, which presumably contained the DM gene, was extensively characterized. Two genomic probes and 2 homologous cDNA probes were situated within approximately 10 kb of genomic DNA and detected an unstable genomic segment in myotonic dystrophy patients. The length variation in this segment showed similarities to the instability seen in the fragile X locus (300624). The authors proposed that the length variation was compatible with a direct role in the pathogenesis of myotonic dystrophy. Using positional cloning strategies, Brook et al. (1992) identified a CTG triplet repeat that is larger in myotonic dystrophy patients than in unaffected individuals. This sequence is highly variable in the normal population. Unaffected individuals have between 5 and 27 copies. Myotonic dystrophy patients who are minimally affected have at least 50 repeats, while more severely affected patients have expansion of the repeat-containing segment up to several kilobase pairs. Tsilfidis et al. (1992) found a correlation between the length of the CTG trinucleotide repeat and the occurrence of severe congenital myotonic dystrophy. Furthermore, mothers of congenital DM individuals had higher than average CTG repeat lengths. Shelbourne et al. (1993) described a probe that allowed direct identification of the myotonic dystrophy mutation in 108 of 112 unrelated patients. In 3 families for whom the clinical and genetic data obtained with linked probes were ambiguous, the specific probe identified persons at risk and demonstrated that a possible sporadic case of myotonic dystrophy was, in fact, familial. In 1 family, the size of the unstable myotonic dystrophy-specific fragment decreased on transmission to offspring who remained asymptomatic, which was an example of the reverse of anticipation. Thornton et al. (1994) reported the clinical findings, muscle pathology, and genetic data on 3 individuals from 2 families with myotonic dystrophy in whom no trinucleotide repeat expansion was detected. The diagnosis of DM was based on involvement of the lens, cardiac conduction system, skin, and testes, in association with muscle weakness and myotonia. The diagnosis was supported by an autosomal dominant pedigree pattern and by features of muscle histopathology consistent with DM. This may be a situation like that of the fragile X syndrome in which rare affected individuals lack a trinucleotide repeat expansion and instead have deletions or point mutations. Martorell et al. (1995) determined the CTG repeat length in 23 DM patients with varying clinical severity and various sizes of repeat amplification. They confirmed the findings of previous studies that there was no strong correlation between repeat length and clinical symptoms but found that the repeat length in peripheral blood cells of patients increased over a 5-year period, indicating continuing mitotic instability of the repeat throughout life. The degree of expansion correlated with the initial repeat size, and 50% of the patients with continuing expansion showed clinical progression of their disease symptoms over the 5-year study period. Junghans et al. (2001) hypothesized that the diversity of phenotype in myotonic dystrophy may be due to the fact that the DM CTG repeat induces long-range cis chromosomal effects that suppress diverse genes on chromosome 19, resulting in manifest multisystem abnormalities in the clinical disorder. One of the features discussed in detail was hypercatabolism of immunoglobulin G in myotonic dystrophy and the possible significance of the FCGRT gene (601437) to the DM locus. Using triplet-primed PCR (TP-PCR) of both DNA strands followed by direct sequencing, Musova et al. (2009) identified interruptions within expanded DM1 CTG repeats in almost 5% (3 of 63) of Czech DM1 families and in 2 of 2 intermediate alleles. None of 261 normal Czech alleles tested carried interruptions. The expanded alleles contained either regular runs of a (CCGCTG)n hexamer or showed a much higher complexity; they were always located at the 3-prime end of the repeat. The number and location of the interruptions were very unstable within families and subject to substantial change during transmission. However, 4 of 5 transmissions of the interrupted expanded allele in 1 family were accompanied by repeat contraction, suggesting that the interruptions render the DMPK CTG repeat more stable or could even predispose it to contractions. Overall, the contribution of the interrupted alleles to the phenotype was uncertain. Musova et al. (2009) suggested that the occurrence of interruptions may be missed by routine testing using PCR or Southern blotting. - Anticipation Buxton et al. (1992) found that the size of the fragment varied between affected sibs and also increased through generations in parallel with increasing severity of the disease. They reported a family in which persons in the first 2 generations had mild symptoms and a CTG repeat unit of approximately 60 repeats, whereas persons in the third and fourth generations had severe symptoms and a dramatic expansion in allele size--a demonstration of the physical basis of anticipation in myotonic dystrophy. Mahadevan et al. (1992) found an expansion of the CTG repeat region in the 3-prime untranslated region of the DM candidate gene in 253 of 258 (98%) persons with DM. They likewise observed that an increase in the severity of the disease in successive generations was accompanied by an increase in the number of trinucleotide repeats. Thus, 'anticipation' (progressively earlier onset and greater severity of symptoms), long a puzzling feature of DM, has an explanation and physical documentation in the progressive 'worsening' of the mutation. Buxton et al. (1992) postulated that this represented an unstable DNA sequence responsible for DM. Tsilfidis et al. (1992) also examined the amount of intergenerational amplification in DM mother/offspring pairs. The average increase in the pairs with congenital DM was not statistically greater than that shown by noncongenital DM pairs. It was noteworthy, however, that whereas 9 of 42 cases (21%) showed no intergenerational amplification between mother and noncongenital offspring, all mother/congenital offspring pairs showed intergenerational amplification. In another analysis, they found that the intergenerational CTG repeat length increase was the same whether the father or the mother contributed the DM allele to the offspring. Fu et al. (1992) reported that in the case of severe congenital DM, the paternal triplet repeat allele was inherited unaltered, while the maternal, DM-associated allele was unstable. They suggested that the mutational mechanism leading to DM is triplet repeat amplification, similar to that occurring in the fragile X syndrome. The genomic repeat is p(AGC)n. Richards and Sutherland (1992), therefore, referred to the trinucleotide repeat as p(AGC)n/p(CTG)n. They pointed out that this is the same repeat sequence found in the androgen receptor gene (313700) and amplified in Kennedy disease (313200), although transcription in the latter disorder is from the opposite strand of DNA. Richards and Sutherland (1992) indicated that the instability of the DM element extends beyond meiotic instability in affected pedigrees to mitotic instability, manifest as somatic variation--a smear of bands evident in some affected persons. Progression of somatic CTG repeat length heterogeneity in the blood cells of myotonic dystrophy patients was documented by Martorell et al. (1998). They studied repeat length changes over time intervals of 1 to 7 years in 111 myotonic dystrophy patients with varying clinical severity and CTG repeat sizes. There was a correlation between the progression of size heterogeneity over time and the initial CTG repeat size. The expansion of a CTG trinucleotide repeat, which represents the myotonic dystrophy mutation, is in complete linkage disequilibrium in both Caucasian (Harley et al., 1991) and Japanese (Yamagata et al., 1992) patients with a 2-allele insertion/deletion polymorphism located 5 kb upstream from the repeat, suggesting a single origin of the mutation. This finding was unexpected for a dominant disease that in its severe form diminishes or abolishes reproductive fitness. Such diseases are usually characterized by a high level of new mutations that compensate for the loss of abnormal alleles due to the decreased fitness. It was therefore suggested that DM could be due to recurrent mutations occurring on the background of a predisposing allelic form of the normal gene. Imbert et al. (1993) studied the association of CTG repeat alleles in a normal population to alleles of the insertion/deletion polymorphism and of a (CA)n repeat marker 90 kb from the DM mutation. The results strongly suggested that the initial predisposing event(s) consisted of a transition from a (CTG)-5 allele to an allele with 19 to 30 repeats. The heterogeneous class of (CTG)-19-30 alleles, which was found to have an overall frequency of about 10%, may constitute a reservoir for recurrent DM mutations. Krahe et al. (1995) reported results in a Nigerian (Yoruba) DM family, the only indigenous sub-Saharan DM case reported to that time, that caused them to reassess the hypotheses that (1) the predisposition for (CTG)n instability resulted from a founder effect that occurred only once or a few times in human evolution; and (2) elements within the disease haplotype may predispose the (CTG)n repeat to instability. (A single haplotype composed of 9 alleles within and flanking the DM locus over a physical distance of 30 kb had been shown to be in complete linkage disequilibrium with DM.) All affected members of the Nigerian family had an expanded (CTG)n repeat in one allele of the DM gene. However, unlike all other DM populations studied to that time, disassociation of the (CTG)n repeat expansion from other alleles of the putative predisposing haplotype was found. Krahe et al. (1995) concluded that in this family, the expanded (CTG)n repeat was the result of an independent mutational event. This weakens the hypothesis that a single ancestral haplotype predisposes to repeat expansion. Yamagata et al. (1996) studied linkage disequilibrium between CTG repeats and an Alu insertion/deletion polymorphism in the DMPK gene (605377) in 102 Japanese families, of which 93 were affected with DM. All of the affected chromosomes were in complete linkage disequilibrium with the Alu insertion allele. A strikingly similar pattern of linkage disequilibrium observed in European populations suggested a common origin of the DM mutation in the Japanese and European populations. The authors speculated that this mutation arose in a common Eurasian ancestor after the first separation of the African and the non-African populations, in light of the fact that the family reported by Krahe et al. (1995) did not show linkage disequilibrium with the Alu insertion/deletion polymorphism. Presumably, the mutation in that family represented a less-ancient event than the Eurasian mutation, accounting for the fact that DM is extremely rare in African populations. Harley et al. (1993) demonstrated in 439 individuals affected with myotonic dystrophy from 101 kindreds that the size of the unstable CTG repeat detected in nearly all cases was related both to age at onset of the disorder and to the severity of the phenotype. The largest repeat sizes, 1.5 to 6.0 kb, were seen in patients with congenital myotonic dystrophy, while the minimally affected patients had repeat sizes of less than 0.5 kb. Only 4 of 182 parent-child pairs showed a definite decrease in repeat size in the offspring; almost all showed that the offspring had an earlier age of onset and a larger repeat size than their parents. Increase in repeat size from parent to child was similar for both paternal and maternal transmissions when the increase was expressed as a proportion of the parental repeat size. Analysis of congenitally affected cases showed not only that they had on the average the largest repeat sizes, but also that their mothers had larger mean repeat sizes, supporting previous suggestions that a maternal effect is involved. Brunner et al. (1993) examined the kinetics of triplet expansion by analyzing repeat length in offspring of 38 carriers with small mutations (less than 100 CTG trinucleotides). Repeat lengths greater than 100 were more common in offspring of male transmitters than in offspring of female transmitters. They suggested that selection against sperm with extreme amplifications may be required to explain maternal inheritance of congenital myotonic dystrophy. Sutherland and Richards (1992) editorialized on the legitimization of anticipation. According to Harper et al. (1992), 'The history of the scientific study of anticipation is...to a remarkable degree, the history of myotonic dystrophy.' In the second decade of this century, several observers noticed that ancestors of myotonic dystrophy patients had cataracts but no muscular symptoms themselves. Brunner et al. (1993) and others observed the opposite of anticipation, namely, reverse mutation. They observed 2 families in which an affected father transmitted a normal allele to an offspring; in each case, an expanded CTG trinucleotide repeat decreased in size to the normal range. This was the first report of spontaneous correction of a deleterious mutation upon transmission to unaffected offspring in humans. Abeliovich et al. (1993) likewise observed what they referred to as 'negative expansion': a family in which the affected father had a 3.0-kb expansion of the DM unstable region, and a fetus inherited the mutated gene but with an expansion of only 0.5 kb. See review by Brook (1993). Ashizawa et al. (1994), who referred to the phenomenon as contraction rather than negative expansion, showed that it occurred in 6.4% of 1,489 DM offspring. Approximately one-half of these cases showed clinical anticipation despite the reduced CTG repeat size in the offspring. The most striking examples were 2 cases in which anticipation resulted in congenital DM in the offspring with contractions of the CTG repeat. They did not observe a single case in which the age at onset of DM in the symptomatic offspring was later than the age at onset in the parent, although Harley et al. (1993) reported 3 such cases. Lavedan et al. (1993) found differently sized repeats in various DM tissues from the same individual, which may explain why the size of the mutation observed in lymphocytes does not necessarily correlate with the severity and nature of symptoms. With CTG sequences of more than 0.5 kb, Lavedan et al. (1993) observed that intergenerational variation was greater through female meioses, whereas a tendency to compression was observed almost exclusively in male meioses. For CTG sequences under 0.5 kb, a positive correlation was observed between the size of the repeat and the intergenerational enlargement for both male and female meioses. Anvret et al. (1993) found in 8 patients with myotonic dystrophy that the length of the CTG repeat expansion was greater in DNA isolated from muscle than in DNA isolated from lymphocytes. Dubel et al. (1992) found heterogeneity in the size of amplification in affected identical twins. A family with myotonic dystrophy described by de Jong (1955) was restudied by de Die-Smulders et al. (1994) from the point of view of the long-term effects of anticipation. They defined clinical anticipation as the cascade of mild, adult, childhood, or congenital disease in successive generations. Such clinical anticipation appeared to be a relentless process occurring in all affected branches of the 5-generation family studied. The transition from the mild to the adult type was associated with transmission through a male parent. Stable transmission of the asymptomatic/mild phenotype showed a female transmission bias. Gene loss in the patients in this family was complete, owing to infertility of the male patients with adult-onset disease and the fact that mentally retarded patients did not procreate. Of the 46 at-risk subjects in the 2 youngest generations, only 1 was found to have a full mutation. This is the only subject who may transmit the gene to the sixth generation. No protomutation carriers were found in the fourth and fifth generations. Therefore, it seemed highly probable that the DM gene would be eliminated from this pedigree within 1 generation. Simmons et al. (1998) demonstrated relatively stable transmission of a (CTG)60 repeat allele through 3 generations of a large DM family; only 3 members, all offspring of male carriers, had expansions in the clinically significant range. Barcelo et al. (1994) insisted that there must be a maternal 'additive' factor involved in congenital DM. Their findings suggested that while a high number of repeats seem to be a necessary condition for congenital DM, this alone is not sufficient to explain its exclusive maternal inheritance. This was most clearly reflected in the fact that in their study group, approximately one-quarter of DM cases inherited from affected fathers had repeat numbers equal to or greater than those found in the congenital DM cases with the lowest number of repeats (approximately 700 repeats). Novelli et al. (1995) provided additional evidence that size of repeat was insufficient to explain the severity. Two affected mothers with similar numbers of repeats gave birth to offspring with discordant phenotypes. Childhood and congenital myotonic dystrophy affected the son and the daughter of one sister, with CTG triplet repeats in lymphocytes of 700 and 1,100, respectively. In contrast, the affected son of the other sister had onset mild myotonic dystrophy at age 14 years, despite having 1,400 CTG triplets detected in lymphocytes. Hamshere et al. (1999) found that in patients with CTG expansions of greater than 1.2 kb, there was no significant correlation between the age of onset of symptoms and the size of their repeat. Regression analysis predicted that the absolute size of the CTG repeat may not be a good indicator of the expected age of onset of symptoms when the size of the repeat is 0.4 kb or greater. Khajavi et al. (2001) investigated the mechanism of expansion bias by cloning single lymphoblastoid cells from DM1 patients and normal subjects. In all DM1 cell lines, the expanded CTG repeat alleles gradually shifted toward further expansion by 'step-wise' mutations. Of 29 cell lines, 8 yielded a rapidly proliferating mutant with a gain of large repeat size that became the major allele population, eventually replacing the progenitor allele population. By mixing cell lines with different repeat expansions, the authors found that cells with larger CTG repeat expansion had a growth advantage over those with smaller expansions in culture. This growth advantage was attributable to increased cell proliferation mediated by Erk1 (601795) and Erk2 (176948) activation, which is negatively regulated by p21(WAF1) (116899). The authors designated this phenomenon 'mitotic drive,' which they suggested is a novel mechanism that can explain the expansion bias of DM1 CTG repeat instability at the tissue level, on a basis independent of the DNA-based expansion models. Since the life spans of the DM1 cells were significantly shorter than normal cell lines, the authors hypothesized that DM1 cells drive themselves to extinction through a process related to increased proliferation. Puymirat et al. (2009) reported 2 unrelated French families in which paternal transmission of an expanded CTG repeat resulting in contraction of the repeat in the offspring. In 1 family, 2 affected brothers with 500 and 630 repeats, respectively, transmitted the alleles to their 4 offspring, who had between 260 and 360 repeats. Three of the 4 young adult offspring were asymptomatic. In the second family, the transmitting father had 500 repeats and his 4 asymptomatic young adult children all had 250 repeats. The findings suggested that a paternal factor acts to prevent CTG repeat expansion in DM1.
The overall prevalence of DM1 is estimated to be 1 in 8,000 (Musova et al., 2009).
In the Saguenay region of the province of Quebec, the prevalence of myotonic dystrophy is about 1 in 475; about ... The overall prevalence of DM1 is estimated to be 1 in 8,000 (Musova et al., 2009). In the Saguenay region of the province of Quebec, the prevalence of myotonic dystrophy is about 1 in 475; about 600 cases are known in a population of 285,000. Mathieu et al. (1990) estimated that the prevalence of myotonic dystrophy in the Saguenay-Lac-Saint-Jean region of Quebec province is 30 to 60 times higher than the prevalence in most other regions of the world. They identified 746 patients (673 still alive) distributed in 88 families in this region, and traced all patients to a couple who settled in New France in 1657. De Braekeleer (1991) estimated the prevalence of myotonic dystrophy in the French-Canadian population in the Saguenay-Lac-Saint-Jean region of Quebec province at more than 1/514, as contrasted with the estimate of 1/25,000 for European populations generally. Dao et al. (1992) found no differences in fertility in myotonic dystrophy individuals in the Saguenay-Lac-Saint-Jean region in a case-control study of 373 affected persons who married between 1855 and 1971. Bouchard et al. (1988) reviewed the genetic demography of the disorder. They were unable to demonstrate the selective disadvantage of the DM gene. Ashizawa and Epstein (1991) claimed that DM among ethnic Africans, especially in central and southern Africa, as well as in Cantonese, Thai, and probably Oceanians, has a low prevalence. In their survey they used Duchenne muscular dystrophy as a control and found that it had an incidence similar to that in western nations. They suggested that the findings are consistent with the evolution and migration of the human species from Africa. Novelli et al. (1994) found a low frequency of the 'at risk' CTG alleles (n = repeat number less than 19), postulated to be the basis of the expanded repeats causing myotonic dystrophy, in Albanians, Egyptians, and Italians, whereas they did not detect alleles of this sort in any chromosomes of the Bamilekes, a Bantu-speaking people from central and southern Cameroon. They interpreted the findings as consistent with the low frequency reported by Ashizawa and Epstein (1991) and provided a molecular basis supporting a north Eurasian origin of the DM mutation. Harley et al. (1991) found linkage disequilibrium between DM and the D19S63 marker, the first demonstration of this phenomenon in a heterogeneous DM population. The results suggested that at least 58% of DM patients in the British population, as well as those in a French-Canadian population, are descended from the same ancestral DM mutation. The result was considered entirely consistent with previous population studies which indicated a very low mutation rate in DM (Harper, 1989). (Harley et al. (1992) stated that no case of mutation had been proven.) The DM mutation in the French-Canadian population (Mathieu et al., 1990) appears to have been introduced into Quebec province by one of the original founders over 300 years ago and may have originated in northern Europe before the spread of this population to the British Isles. The remaining 42% of DM chromosomes may include some that have the same mutation (which has become associated with different D19S63 alleles through recombination) together with one or more other DM mutations. Although linkage disequilibrium with other closely linked markers--APOC2 (608083), CKM (123310), and BCL3 (109560)--was not observed in the Welsh population, strong disequilibrium was observed in the French-Canadian population. Goldman et al. (1995) studied the association between normal alleles at the CTG repeat in 2 nearby polymorphisms in the myotonin protein kinase gene in South African Negroids, a population in which myotonic dystrophy had not been described. They found a significantly different CTG allelic distribution from that in Caucasoids and Japanese: CTG repeat lengths greater than 19 were very rare. The striking linkage disequilibrium between specific alleles at the Alu insertion/deletion polymorphism, the HinfI polymorphism of intron 9, and the CTG repeat polymorphism seen in Caucasoids in Europe and Canada was also found in the South African Negroid population. Goldman et al. (1995), however, found numerous haplotypes not previously described in Europeans. Thus it seemed likely that only a small number of these 'African' chromosomes were present in the progenitors of all non-African peoples. The data provided support for the 'out of Africa' model for the origin of modern humans and suggested that the rare ancestral DM mutation event may have occurred after the migration from Africa, thus accounting for the absence of DM in sub-Saharan Negroid peoples. Goldman et al. (1996) reported molecular evidence for a DM founder effect in South African families. DM haplotype I was found in the South African DM population and rarely in the non-DM population. Goldman et al. (1996) noted that both the geographic distribution of families with DM (occurrence primarily in Afrikaans-speaking families who originated in the Northern Transvaal) and a previous genealogic study by Lotz and van der Meyden (1985) also suggested a founder effect as the likely explanation for the high prevalence of DM. Lotz and van der Meyden (1985) found no single case of DM in an indigenous Negroid or Khoisan person from southern Africa, despite a survey representing a population of more than 30 million (Ashizawa and Epstein, 1991). Harley et al. (1992) found that a second polymorphism near the triplet repeat was in almost complete linkage disequilibrium with myotonic dystrophy, strongly supporting these earlier results (Harley et al., 1991) that indicated that most cases are descended from one original mutation. Cobo et al. (1992) found that DM and D19S63 showed linkage disequilibrium in the Spanish population also. They studied 33 Spanish families from 5 different geographic regions. Passos-Bueno et al. (1995) found a relatively low frequency of DM families of black racial background in Brazil. Three of 41 DM families were of that ancestry in the city of Sao Paulo in which 40% of the population was black. The authors thought that bias in ascertainment could not be the explanation. In 72 French families, Lavedan et al. (1994) found that 100% of chromosomes with the DM mutation carried an intragenic 1-kb insertion. They also detected significant linkage disequilibrium between the DM locus and D19S63 for which allelic frequencies were different from other European populations. The results were consistent with the hypothesis that the CTG expansion occurred on one or a few ancestral chromosomes carrying the large 1-kb insertion allele. Goldman et al. (1996) studied the CTG trinucleotide repeat in the DMK gene by PCR analysis in 246 unrelated South African Bantu-speaking Negroids, 116 San and 27 Pygmies. The size and distribution of the CTG repeat were determined and showed that the alleles ranged in length from 5 to 22 repeats. The most common CTG repeat was 5 (25% of chromosomes) in the South African Negroids but 11 (27% of chromosomes) in the San population, and 12 (22% of chromosomes) in the Pygmies. The South African Bantu-speaking Negroids and San thus had significantly larger repeat length alleles than do Caucasoid and Japanese populations. Again, Goldman et al. (1996) concluded that the occurrence of fewer large CTG repeats in the normal range accounts for the absence of DM from Southern African Negroids and suggests that the rare DM mutation event postulated to have occurred on a specific chromosomal haplotype took place originated after the migration of humans from Africa. Deka et al. (1996) analyzed the CTG repeat length and the neighboring Alu insertion/deletion (+/-) polymorphism in DNA samples from 16 ethnically and geographically diverse human populations. They found that the CTG repeat length is variable in human populations. Although the (CTG)5 repeat is the most common allele in most populations, it was absent among Costa Ricans and New Guinea highlanders. They detected a (CTG)4 repeat allele, the smallest CTG known, in an American Samoan individual. Alleles with 19 or more CTG repeats were the most frequent in Europeans, followed by the populations of Asian origin, and are absent or rare in Africans. To understand the evolution of CTG repeats, Deka et al. (1996) used haplotype data from the CTG repeat and Alu(+/-) locus. The results were consistent with previous studies and showed that among individuals of Caucasian and Japanese origin the association of the Alu(+) allele with CTG repeats of 5 and at least 19 is complete, whereas the Alu(-) allele is associated with (CTG)11-16 repeats. However, these associations are not exclusive in non-Caucasian populations. Most significantly, Deka et al. (1996) detected the (CTG)5 repeat allele on an Alu(-) background in several populations including native Africans. As no (CTG)5 repeat allele on an Alu(-) background had been observed hitherto, they proposed that the Alu(-) allele arose on a (CTG)11-13 background. They suggested further that the most parsimonious evolutionary model is (1) that (CTG)5-Alu(+) is the ancestral haplotype; (2) that (CTG)5-Alu(-) arose from a (CTG)5-Alu(+) chromosome later in evolution; and (3) that expansion of CTG alleles occurred from (CTG)5 alleles on both Alu(+) and Alu(-) backgrounds. Tishkoff et al. (1998) studied the origin of myotonic dystrophy mutations by analyzing haplotypes consisting of the (CTG)n repeat, as well as several flanking markers at the myotonic dystrophy locus, in normal individuals from 25 human populations (5 African, 2 Middle Eastern, 3 European, 6 East Asian, 3 Pacific/Australo-Melanesian, and 6 Amerindian) and in 5 nonhuman primate species. They found that non-African populations had a subset of haplotype diversity present in Africa, as well as a shared pattern of allelic association. (CTG)18-35 alleles (large normal) were observed only in northeastern African and non-African populations and exhibited strong linkage disequilibrium with 3 markers flanking the (CTG)n repeat. The pattern of haplotype diversity and linkage disequilibrium observed supported a recent African-origin model of modern human evolution and suggested that the original mutational event that gave rise to DM-causing alleles arose in a population ancestral to non-Africans before migration of modern humans out of Africa. Neville et al. (1994) performed a high-resolution genetic analysis of the DM locus using PCR-based assays of 9 polymorphisms immediately flanking the DM repeat. With the exception of the case reported from Africa by Krahe et al. (1995), all cases of DM in the world appear to share a single haplotype that contains putative at-risk CTG alleles, i.e., alleles with 19 to 30 CTG repeats that may serve as a reservoir for recurrent mutations to unstable alleles with 30 to 50 repeats (Imbert et al., 1993). Yamagata et al. (1998) found 6 different haplotypes in the Japanese population and determined that DM alleles were always haplotype A (in the nomenclature of Neville et al., 1994), the same as in Caucasians. In both Caucasian and Japanese populations, a multistep process of triplet repeat expansion originated by expansion of an ancestral n = 5 repeats to n = 19 to 37 copies. A similar multistep model has been suggested for Friedreich ataxia (229300). Pan et al. (2001) described a low frequency (1.4%) of CTG repeats (larger than 18 repeats) in the Taiwanese population, predicting a low prevalence of DM1. As in Caucasian and Japanese populations, all of the Taiwanese DM1 chromosomes examined were exclusively associated with the Alu insertion and 7 additional single base polymorphic markers (haplotype A). The findings suggested that the Taiwanese, and maybe all non-African, DM1 chromosomes may have originated from a pool of large-sized normal alleles with haplotype A, which was generated after the migration out of Africa. Siciliano et al. (2001) calculated the DM prevalence rates in Padua (northeast Italy) and in 4 provinces in northwest Tuscany (central Italy) using molecular genetic testing. A minimum prevalence rate of 9.31 x 10(-5) persons was found, consistent with epidemiologic rates worldwide, and more than 2 times the size of those of 2 previous studies conducted in the same areas during the era before molecular genetic testing. The results underlined the importance of direct genetic diagnosis of DM, especially in detecting mildly affected patients. In a comprehensive epidemiologic survey among Jews living in Israel, Segel et al. (2003) found that the average prevalence of DM was 15.7 per 100,000 (1 case in 6,369), with intercommunity variations: Ashkenazi Jews had the lowest rate (1 case in 17,544) as compared to those in Sephardi/Oriental Jews and Yemeni Jews (1 case in 5,000 and 1 case in 2,114, respectively). The rate of unrelated DM sibships per million persons of each community was used as an estimate of the transition rate from stable to unstable DMPK-(CTG)n alleles assuming that each transition is a beginning of a new DM sibship. This study indicated that the difference in the incidence of DM is a result of higher mutation rate in the non-Ashkenazi Jews as compared to the rate in the Ashkenazi Jews. The intragenic haplotype of the DM alleles was the same as that in DM patients in many populations worldwide; however, 2 markers closely linked to DM, D19S207 and D19S112, were in linkage disequilibrium with the DM mutation in patients of Yemeni and Moroccan (the largest subgroup of the Sephardi Jews) extractions but not in the Ashkenazi patients. This observation indicated a common ancestral origin for the DM premutation in patients of the same ethnic origin. Segel et al. (2003) concluded that the difference in DM prevalence among the Jewish communities is a consequence of founder premutations in the non-Ashkenazi Jewish communities. Yotova et al. (2005) used SNP and microsatellite markers to characterize a 2.05-Mb DNA segment spanning the DM1-expansion site in 50 DM1 families from northeastern Quebec. The results suggested the existence of 3 basic haplotype families, A, B, and C, with A being the most common. By analyzing proportions of recombinant haplotypes, Yotova et al. (2005) estimated that haplotype A was the 'driver' founder effect, with an age of 9 generations, consistent with the settlement of Charlevoix at the turn of the 17th century and subsequent colonization of Saguenay-Lac-Saint-Jean. The minor haplotypes B and C were likely introduced independently. Medica et al. (2007) found that 4 (1.46%) of 274 unrelated adults with cataract, but no evidence or family history of DM1, carried a 'protomutation' in the DMPK gene ranging between 52 and 81 CTG repeats. The authors hypothesized that these patients with protomutations represented a source of full expansion mutation, which could be responsible for maintaining DM1 mutations in a population. Stable transmission to an unaffected offspring was observed in 1 individual with a protomutation. Three of the patients were from the Croatian region of Istria, which has a high prevalence of DM1. Acton et al. (2007) reported 2 African American brothers from Alabama who had DM1, both with CTG repeats of 5/639; their father was reportedly affected and had CTG repeats of 5/60. Other unaffected family members had CTG repeats of 5 to 14. Another unrelated African American patient from Alabama had CTG repeats of 27/191. Among 161 African American controls from Alabama, the authors observed 18 CTG alleles from 5 to 28 repeats. A comparison with other ethnic groups showed that the African American individuals from Alabama had more CTG repeats than some African black populations, but fewer than European white or Japanese populations. These data suggested that the risk for DM1 in American blacks is intermediate between that of African blacks and whites of European descent. Suominen et al. (2011) found 2 DM1 mutations among 4,520 Finnish control individuals and no DM1 mutations among 988 Finnish patients with a neuromuscular disorder. One of the expanded DM1 mutations had 80 repeats, but the size of the other expansion could not be determined. Overall, the DM1 mutation frequency was estimated to be 1 in 2,760 in the general population. In the same study, the frequency of DM2 was estimated to be 1 in 1,830. Suominen et al. (2011) stated that these estimates were significantly higher than previously reported estimates, which they cited as 1 in 8,000 for both DM1 and DM2.
Myotonic dystrophy type 1 (DM1) is suspected in adults with the following: ...
Diagnosis
Clinical DiagnosisMyotonic dystrophy type 1 (DM1) is suspected in adults with the following: Muscle weakness, especially of the distal leg, hand, neck, and face Myotonia (sustained muscle contraction), which often manifests as the inability to quickly release a hand grip (grip myotonia) and which can be demonstrated by tapping a muscle (e.g., the thenar muscles) with a reflex hammer (percussion myotonia) Posterior subcapsular cataracts detectable as red and green iridescent opacities on slit lamp examination DM1 is suspected in neonates with some combination of the following:Hypotonia Facial muscle weakness Generalized weakness Positional malformations including club foot Respiratory insufficiency TestingNon-molecular testing that has been used in the past to establish the diagnosis of DM1 currently has little role in diagnosis and is primarily used if molecular testing of DMPK does not identify the CTG repeat expansion and other myopathies are being considered. Tests include the following: Electromyography (EMG). A needle electrode placed in the muscle of an affected adult records myotonic discharges and myopathic-appearing motor units, predominantly in distal muscles. Electrical myotonic discharges are not usually seen during infancy, but fast runs of single fiber discharges approaching the pattern of myotonic discharges are suggestive. Serum CK concentration. Serum CK concentration may be mildly elevated in individuals with DM1 with weakness, but is normal in asymptomatic individuals. Muscle biopsy. Pathologic features observed on muscle biopsy include rows of internal nuclei (having a box car appearance), ring fibers, sarcoplasmic masses, type I fiber predominance and atrophy, fibrosis and fatty infiltration, and a greatly increased number of intrafusal muscle fibers [Thornton 2002]. Molecular Genetic Testing Gene. DMPK is the only gene in which mutations are known to cause myotonic dystrophy type 1 (DM1). Essentially 100% of individuals with DM1 have an increased number (i.e., an expansion) of the CTG trinucleotide repeat in DMPK. Allele sizes. Reference ranges for allele sizes were established by the Second International Myotonic Dystrophy Consortium (IDMC) in 1999 [International Myotonic Dystrophy Consortium 2000, Moxley & Meola 2008] See Prior [2009] and Kamsteeg et al [2012] for technical standards and guidelines for testing. Normal alleles: 5-34 CTG repeats Mutable normal (premutation) alleles: 35-49 CTG repeats. Individuals with CTG expansions in the premutation range have not been reported to have symptoms, but their children are at increased risk of inheriting a larger repeat size and thus having symptoms [Martorell et al 2001]. Full penetrance alleles: >50 CTG repeats. Full penetrance alleles are associated with disease manifestations. See Published Guidelines.Clinical testing Table 1. Summary of Molecular Genetic Testing Used in Myotonic Dystrophy Type 1View in own windowGene Symbol Test MethodMutations DetectedMutation Detection Frequency by Test Method 1Test AvailabilityDMPKTargeted mutation analysis
CTG trinucleotide repeat expansion100% 2Clinical1. The ability of the test method used to detect a mutation that is present in the indicated gene2. Testing to quantitate the number of DMPK CTG trinucleotide repeats is performed by PCR analysis, which reliably detects expanded alleles with about 100-150 CTG repeats. Detection of larger CTG expansions requires Southern blot analysis. Testing StrategyTo confirm/establish the diagnosis in a proband. A diagnostic algorithm for evaluating patients with myotonia is described by Moxley & Meola [2008]. Molecular genetic testing of DMPK is the basis of diagnosis of DM1. Non-molecular testing used in the past to establish the diagnosis of DM1 currently has little role in diagnosis; it is primarily used if molecular testing of DMPK does not identify the CTG repeat expansion. Predictive testing for at-risk asymptomatic adult family members requires prior identification of the disease-causing mutation in the family.Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require prior identification of the disease-causing mutation in the family.Genetically Related (Allelic) DisordersNo phenotypes other than those discussed in this GeneReview are known to be associated with mutations in DMPK.
Clinical findings in myotonic dystrophy type 1 (DM1) span a continuum from mild to severe. Udd & Krahe [2012] provide an excellent overview of all aspects of DM1. The clinical findings have been categorized into three somewhat overlapping phenotypes (mild, classic, and congenital) that generally correlate with CTG repeat size (Table 2). The CTG repeat ranges for the phenotypes in Table 2 have considerable overlap and caution must be used in predicting disease severity on the basis of CTG repeat size [Gharehbaghi-Schnell et al 1998, International Myotonic Dystrophy Consortium 2000, Harper 2001, Moxley & Meola 2008]....
Natural History
Clinical findings in myotonic dystrophy type 1 (DM1) span a continuum from mild to severe. Udd & Krahe [2012] provide an excellent overview of all aspects of DM1. The clinical findings have been categorized into three somewhat overlapping phenotypes (mild, classic, and congenital) that generally correlate with CTG repeat size (Table 2). The CTG repeat ranges for the phenotypes in Table 2 have considerable overlap and caution must be used in predicting disease severity on the basis of CTG repeat size [Gharehbaghi-Schnell et al 1998, International Myotonic Dystrophy Consortium 2000, Harper 2001, Moxley & Meola 2008].Table 2. Correlation of Phenotype and CTG Repeat Length in Myotonic Dystrophy Type 1View in own windowPhenotypeClinical Signs CTG Repeat Size 1, 2 Age of OnsetAverage Age of DeathMutable normal (premutation)
None 35 to 49 NA 3 NA 3 Mild Cataracts Mild myotonia 50 to ~150 20 to 70 yrs60 yrs to normal life spanClassic Weakness Myotonia Cataracts Balding Cardiac arrhythmia Others ~100 to ~1000 10 to 30 yrs48 to 55 yrs Congenital Infantile hypotonia Respiratory deficits Intellectual disability Classic signs present in adults >1000 4 Birth to 10 yrs45 yrs 5 From de Die-Smulders et al [1998], Mathieu et al [1999], International Myotonic Dystrophy Consortium [2000] 1. CTG repeat sizes are known to overlap between phenotypes.2. Normal CTG repeat size is 5-34.3. NA = not applicable4. Redman et al [1993] reported a few individuals with congenital DM1 with repeats between 730 and 1000. 5. Does not include neonatal deathsMild DM1Individuals with mild DM1 may have only cataract, mild myotonia, or diabetes mellitus. They may have fully active lives and a normal or minimally shortened life span [Arsenault et al 2006]. Classic DM1Within this range of CTG repeat size, only a rough correlation with severity of symptoms exists. Individuals with CTG repeat sizes in the 100-to-1000 range usually develop classic DM1 with muscle weakness and wasting, myotonia, cataracts, and often cardiac conduction abnormalities. While the age of onset for classic DM1 is typically in the 20s and 30s (and less commonly after age 40 years), classic DM1 may be evident in childhood, when subtle signs such as myotonic facies and myotonia are observed.Muscle. In individuals with classic DM1, the predominant symptom is distal muscle weakness, leading to foot drop/gait disturbance and difficulty with performing tasks requiring fine dexterity of the hands. The typical facies is mainly caused by weakness of the facial and levator palpebrae muscles. Myotonia may interfere with daily activities such as using tools, household equipment, or doorknobs. Handgrip myotonia and strength may improve with repeated contractions (the so-called warm-up phenomenon) [Logigian et al 2005]. The warm-up phenomenon can also improve dysarthric speech [de Swart et al 2004].Fatigue is a common finding [Kalkman et al 2005].Cardiac. Cardiac conduction defects of varying degrees of severity are common. In one series, 90% of individuals had conduction defects. These defects are a significant cause of early mortality in individuals with DM1, sometimes associated with sudden death. Less commonly, cardiomyopathy may occur [Bassez et al 2004, Chebel et al 2005, Dello Russo et al 2006, Gagnon et al 2007, Sovari et al 2007, Breton & Mathieu 2009, Mörner et al 2010, Petri et al 2012, Turkbey et al 2012].GI. Smooth muscle involvement may produce dysphagia, constipation, intestinal pseudo-obstruction, or diarrhea [Bellini et al 2006]. Orophayngeal dysphagia and swallowing problems have been studied by Ercolin et al [2013].Gallstones occur as a result of increased tone of the gall bladder sphincter.Liver function tests (e.g., transaminases) are often elevated for unclear reasons [Heatwole et al 2006].Cognition and CNS changes. Minor intellectual deficits are present in some individuals, but in others intelligence may be incorrectly assumed to be reduced because of the dull facial expression. Age-related cognitive decline has been reported in some adults [Modoni et al 2004, Gaul et al 2006, Sansone et al 2007, Modoni et al 2008]. Frontal-parietal lobe deficits have been documented on formal testing [Sistiaga et al 2010].Avoidant, obsessive-compulsive, and passive-aggressive personality features have been reported [Delaporte 1998, Winblad et al 2005].Anxiety and depression are often seen and general quality of life can be seriously impaired [Antonini et al 2006].Hypersomnia and sleep apnea are other well-recognized manifestations that appear later [Rubinsztein et al 1998, Laberge et al 2009]. Excessive daytime sleepiness is often caused by a central dysfunction of sleep regulation, but all types of sleep disorders have been reported [Dauvilliers & Laberge 2012]. Fifty percent of 40 individuals with DM1 had obstructive sleep apnea [Pincherle et al 2012].Brain MRI may demonstrate mild cortical atrophy and white matter abnormalities. The white matter changes can be diffuse and extensive [Minnerop et al 2011, Wozniak et al 2013].At autopsy brain neurons may contain tau-associated neurofibrillary tangles [Maurage et al 2005, Oyamada et al 2006]. Nerve. An axonal peripheral neuropathy may add to the weakness but may be uncommon [Krishnan & Kiernan 2006, Bae et al 2008]. Peric et al [2013] found evidence of neuropathy by nerve conduction studies in one third of 111 individuals with DM1. Eye. Cataracts can eventually be observed as having characteristic multi-colored “Christmas tree” appearance by slit lamp examination in nearly all affected individuals. They may cause visual symptoms at any age, but usually in the 30s-40s. Some affected individuals have ophthalmoplegia.Endocrine. Endocrinopathies including hyperinsulinism, thyroid dysfunction, diabetes mellitus, calcium dysregulation, testicular atrophy, and possible abnormalities in growth hormone secretion can be observed, although they are rarely clinically significant. Infertility may occur in otherwise asymptomatic persons [Garcia de Andoin et al 2005, Matsumura et al 2009]. The largest published study of these endocrine abnormalities is that of Orngreen et al [2012].Skin. Pilomatrixomata and epitheliomas can occur, especially on the scalp, and can be confused with sebaceous cysts [Geh & Moss 1999, Cigliano et al 2005]. Cancer risk. Win et al [2012] found that individuals with DM1 may be at increased risk for thyroid cancer, choroidal melanoma, and possibly testicular and prostate cancers. Additional studies are needed. Disease course. Rarely, after several decades of disease, DM1 progresses to the point of wheelchair confinement. Weakness/myotonia of the diaphragm and a susceptibility to aspiration increase the risk for respiratory compromise, usually in individuals with advanced disease [Roses 1997]. Several studies have evaluated life span and mortality in DM1 (Table 2) [de Die-Smulders et al 1998, Mathieu et al 1999]. The most common causes of death are pneumonia/respiratory failure, cardiovascular disease, sudden death/arrhythmia, and neoplasms. In the study of de Die-Smulders et al [1998] 50% of individuals with DM1 were either partially or totally wheelchair bound shortly before death. The cumulative probability of 15-year survival in Belgrade was 50% [Mladenovic et al 2006]. Both early age of onset and decreased survival correlate with larger CTG repeat expansions [Groh et al 2011].Congenital DM1A transmission ratio distortion at conception favors transmission of larger CTG repeats than those present in the parent [Dean et al 2006]. The mother is almost always the parent who transmits the larger repeat, although transmission by the father has been reported [Zeesman et al 2002]. Presence of a large repeat may lead to earlier onset and more severe disease, known as congenital DM1 [De Temmerman et al 2004, Rakocevic-Stojanovic et al 2005]. Congenital DM1 often presents before birth as polyhydramnios and reduced fetal movement.After delivery, the main features are severe generalized weakness, hypotonia, and respiratory compromise. Typically, affected infants have an inverted V-shaped (also termed 'tented or 'fish'-shaped) upper lip, which is characteristic of significant facial diplegia (weakness). Mortality from respiratory failure is common. Surviving infants experience gradual improvement in motor function. Affected children are usually able to walk; however, a progressive myopathy occurs eventually, as in the classic form [Harper 2001]. These individuals may develop any of the typical features of DM1 including weakness, myotonia, cataracts, and cardiac problems.Intellectual disability is present in 50%-60% of individuals with congenital DM1. The cause of the intellectual disability is unclear, but cerebral atrophy and ventricular dilation are often evident at birth. Intellectual disability may result from a combination of early respiratory failure and a direct effect of the DMPK mutation on the brain [Spranger et al 1997, Ekström et al 2009]. Autism spectrum disorder may be observed [Ekström et al 2008]. Douniol et al [2012] have reported common mood/anxiety disorders, impaired attention, and abnormal visual-spatial abilities. Children with DM1 may have low visual acuity, hyperopia, or astigmatism [Ekström et al 2010].
Table 3. Myotonic Dystrophy: OMIM Phenotypic SeriesView in own windowPhenotypePhenotype MIM NumberGene/LocusGene/Locus MIM NumberMyotonic dystrophy 1
160900 DMPK, DM, DMK 605377Myotonic dystrophy 2 602668 ZNF9, CNBP1, DM2, PROMM 116955 Data from Online Mendelian Inheritance in ManThe distinction between myotonic dystrophy type 1 (DM1) and other inherited myopathies is made by determining the number of CTG repeats in DMPK.Myotonic dystrophy type 2 (DM2) is characterized by myotonia (90% of affected individuals) and muscle dysfunction (weakness, pain, and stiffness) (82%), and less commonly by cardiac conduction defects, iridescent posterior subcapsular cataracts, insulin-insensitive type 2 diabetes mellitus, and testicular failure. Although myotonia has been reported during the first decade, onset is typically in the third decade, most commonly with fluctuating or episodic muscle pain that can be debilitating and weakness of the neck flexors and finger flexors. Subsequently, weakness occurs in the elbow extensors and the hip flexors and extensors. Facial weakness and weakness of the ankle dorsiflexors are less common. Myotonia rarely causes severe symptoms. A detailed comparison between DM1 and DM2 has been reported [Turner & Hilton-Jones 2010]. CNBP (ZNF9) is the only gene in which mutations are known to cause myotonic dystrophy type 2. CNBP intron 1 contains a complex repeat motif, (TG)n(TCTG)n(CCTG)n. Expansion of the CCTG repeat causes DM2. The number of CCTG repeats in expanded alleles ranges from approximately 75 to more than 11,000, with a mean of approximately 5000 repeats. The detection rate of a CNBP CCTG expansion is more than 99% with the combination of routine PCR, Southern blot analysis, and the "PCR repeat assay." Inheritance is autosomal dominant.No other genetic causes of multisystem myotonic dystrophies have been identified, although they likely exist. The International Myotonic Dystrophy Consortium (IDMC) has agreed that any newly identified multisystem myotonic dystrophies will be sequentially named as forms of myotonic dystrophy. One family posited to have DM3 [Le Ber et al 2004] was subsequently shown to have an unusual presentation of inclusion body myopathy with Paget disease and frontotemporal dementia (IBMPFTD) [Udd et al 2006], caused by mutations in VCP. If the DMPK CTG repeat length is in the normal range and if DM2 has been excluded by molecular genetic testing of CNBP, further testing with EMG, serum CK concentration, and/or muscle biopsy is often warranted to evaluate for other causes of muscle disease. The differential diagnosis for hereditary distal myopathies includes hereditary inclusion body myopathy (IBM), hereditary myofibrillar myopathy (MFM), distal muscular dystrophy (e.g., Miyoshi, Nonaka, Welander, Markesbery-Griggs), and the limb-girdle muscular dystrophies.Other hereditary disorders associated with myotonia are myotonia congenita (also called Thomsen disease or Becker disease), caused by mutations in CLCN1, paramyotonia congenita and its variants, caused by mutations in SCN4A, and hyperkalemic periodic paralysis, caused by mutations in SCN4A.Occasionally, DM1 has been misdiagnosed as motor neuron disease (see Spinal Muscular Atrophy and Spinal and Bulbar Muscular Atrophy), cerebral palsy, nonspecific intellectual disability, or, because of 'masked face' and slow movements, parkinsonism.Note to clinicians: For a patient-specific ‘simultaneous consult’ related to this disorder, go to , an interactive diagnostic decision support software tool that provides differential diagnoses based on patient findings (registration or institutional access required).Mild DM1Classic DM1Congenital DM1
To establish the extent of disease and needs in children diagnosed with congenital myotonic dystrophy type 1 (DM1), the following evaluations are recommended:...
Management
Evaluations Following Initial DiagnosisTo establish the extent of disease and needs in children diagnosed with congenital myotonic dystrophy type 1 (DM1), the following evaluations are recommended:Baseline neurologic examination Baseline ophthalmologic examination Assessment of motor skills Assessment of cognitive ability Medical genetics consultationTo establish the extent of disease and needs in adults with classic DM1, the following evaluations are recommended:Baseline neurologic examination Baseline examination by an ophthalmologist familiar with the iridescent posterior subcapsular cataract characteristic of DM1 Assessment of thyroid function ECG, Holter monitoring, and echocardiogram to evaluate syncope, palpitations, and other symptoms of potential cardiac origin Assessment of strength [Whittaker et al 2006] Assessment of cognitive ability Fasting blood glucose determination Medical genetics consultationTreatment of ManifestationsNo specific treatment exists for the progressive weakness in individuals with DM1.A physiatrist, occupational therapist, or physical therapist can help evaluate affected individuals regarding the need for ankle-foot orthoses, wheelchairs, or other assistive devices as the disease progresses. Orthopedic surgery may benefit children with musculoskeletal deformities [Canavese & Sussman 2009].Increased weakness in DM1 has been associated with both hypothyroidism and certain cholesterol-lowering medications (i.e. statins), so that some strength can return if these causative factors are eliminated.Myotonia in DM1 is typically mild to moderate and rarely requires treatment [Ricker et al 1999]. Anecdotally, some individuals have responded to mexilitene or carbamazepine. Logigian et al [2010] found mexilitene 150-200 mg TID effective and safe for treating myotonia.Pain management can be an important part of DM1 treatment. Different medications and combinations of medications work for some individuals, although none has been routinely effective; medications that have been used include mexilitene, gabapentin, nonsteroidal anti-inflammatory drugs (NSAIDs), low-dose thyroid replacement, low-dose steroids, and tricyclic antidepressants. When used as part of a comprehensive pain management program, low-dose analgesics may provide relief.Consultation with a cardiologist is appropriate for individuals with cardiac symptoms or ECG evidence of arrhythmia because fatal arrhythmias can occur prior to other symptoms in individuals with DM1. More advanced, invasive electrophysiologic testing of the heart may be required [Sovari et al 2007].Cataracts can be removed if they impair vision. Recurrence after surgery has been reported [Garrott et al 2004].Males with low serum concentration of testosterone require hormone replacement therapy if they are symptomatic. In most cases, surgical excision of pilomatrixoma including clear margins and its overlying skin is the preferred treatment [Cigliano et al 2005].An extensive review found no evidence for treatment of hypersomnia with routine psychostimulants [Annane et al 2006].Prevention of Secondary ComplicationsVeyckemans & Scholtes [2013] have reviewed the anesthetic management of individuals with DM1. Choice of induction agents, airway care, local anesthesia, and neuromuscular blockade were found to minimize complications during surgery in individuals with DM1. Cardiac pacemakers or implantable cardioverter-defibrillators may prevent life-threatening arrhythmias [Wahbi et al 2012, Facenda-Lorenzo et al 2013].Gagnon et al [2013] presented evidence that obesity, tobacco smoking, physical inactivity and alcohol/illicit drug consumption are lifestyle risk factors associated with more severe DM1 phenotypes.SurveillanceThe following are appropriate:Annual ECG to detect asymptomatic cardiac conduction defects. Some centers perform annual 24-hour Holter monitoring of individuals with DM1 who do not have cardiac symptoms [Sá et al 2007, Sovari et al 2007, Cudia et al 2009]. Tissue Doppler monitoring has also been proposed [Parisi et al 2007, Wahbi et al 2012]. Annual measurement of fasting serum glucose concentration and glycosylated hemoglobin concentration, with treatment for diabetes mellitus if indicated [Matsumura et al 2009]Ophthalmologic examination every two years to evaluate for cataract formation Attention to nutritional status including mastication and trouble eating [Motlagh et al 2005, Engvall et al 2009, Umemoto et al 2009]Polysomnographic follow-up of sleep complaints [Kumar et al 2007]Agents/Circumstances to AvoidStatins used to lower cholesterol may sometimes cause muscle pain and weakness. Mathieu et al [1997] noted that “[n]umerous cases of perioperative complications in patients with DM have been reported. Hazards have been associated with the use of thiopentone, suxamethonium, neostigmine, and halothane. A retrospective study of perioperative complications was conducted for 219 patients who had their first surgery under general anesthesia at the Chicoutimi Hospital. The overall frequency of complications was 8.2% (18 of 219). Most complications (16 of 18) were pulmonary, including five patients with acute ventilatory failure necessitating ventilatory support, four patients with atelectasis, and three patients with pneumonia. Using multivariate analysis, [the authors] found that the risk of perioperative pulmonary complications (PPC) was significantly higher after an upper abdominal surgery and for patients with a severe muscular disability, as assessed by the presence of proximal limb weakness. The likelihood of PPC was not related to any specific anesthetic drug. Because of the increased risk of PPC, careful monitoring during the early postoperative period, protection of the upper airways, chest physiotherapy, and incentive spirometry are mandatory in all symptomatic patients with DM, particularly those with a severe muscular disability or those who have undergone an upper abdominal surgery.”Malignant hyperthermia during anesthesia including the use of vecuronium [Nishi et al 2004] has been reported in DM1 but is very uncommon [Kirzinger et al 2010]. (See Malignant Hyperthermia Susceptibility.)Aggressive doxorunbicin-based chemotherapy for lymphoma in a person with DM1 produced sudden atrial fibrillations [Montella et al 2005]. Evaluation of Relatives at RiskIt is appropriate to offer molecular genetic testing to at-risk adult relatives to allow early diagnosis and treatment of cardiac manifestations, diabetes mellitus, and cataracts.See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.Pregnancy Management Women with DM1 are at risk for complications during pregnancy including increased spontaneous abortion rate, premature labor, prolonged labor, retained placenta, placenta previa, and postpartum hemorrhage [Zaki et al 2007, Argov & de Visser 2009]. Special surveillance during pregnancy of women with DM1 includes ultrasound examination; evaluation for placenta previa; and anticipation of possible polyhydramnios, prolonged labor, and/or need for delivery by cesarean section [Argov & de Visser 2009]. Complications related to the presence of congenital DM1 in the fetus include reduced fetal movement and polyhydramnios. There is an increase in the rates of caesarean births and preterm deliveries [Awater et al 2012].Therapies Under InvestigationTreatment trials of myotonia are few in number and not carefully conducted [Trip et al 2006]. Ideas for new pharmacologic approaches are reviewed by Wheeler [2008] and by Foff & Mahadevan [2011] including RNA and small molecule approaches. Gao & Cooper [2013] discuss the potential use of antisense oligonucleotides.Heatwole et al [2011] reported no increase in muscle strength or function in a pilot study of recombinant human insulin-like growth factor; however, they recommended that a larger control trial be performed. Search ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions.OtherModerate-intensity strength training does no harm, but it is unclear whether it offers measurable benefits [van der Kooi et al 2005]. A controlled study of an exercise program for DM1 showed neither beneficial nor detrimental effects [Kierkegaard et al 2011].
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED....
Molecular Genetics
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.Table A. Myotonic Dystrophy Type 1: Genes and DatabasesView in own windowGene SymbolChromosomal LocusProtein NameLocus SpecificHGMDDMPK19q13.32
Myotonin-protein kinaseDMPK homepage - Mendelian genesDMPKData are compiled from the following standard references: gene symbol from HGNC; chromosomal locus, locus name, critical region, complementation group from OMIM; protein name from UniProt. For a description of databases (Locus Specific, HGMD) to which links are provided, click here.Table B. OMIM Entries for Myotonic Dystrophy Type 1 (View All in OMIM) View in own window 160900MYOTONIC DYSTROPHY 1; DM1 605377DYSTROPHIA MYOTONICA PROTEIN KINASE; DMPKNormal allelic variants. DMPK has 14 exons covering approximately 13 kb of genomic DNA Normal allelic variants have 5-34 CTG repeats. Alleles with 35-49 CTG repeats are normal mutable (or premutation) alleles. Individuals with CTG expansions in the premutation range have not been reported to have symptoms, but their children are at increased risk of inheriting a larger repeat size and thus having symptoms [Martorell et al 2001]. Pathologic allelic variants. Myotonic dystrophy type 1 (DM1) appears to be caused by a single mutational mechanism: expanded CTG trinucleotide repeat (>49). Other types of mutations (e.g., point mutations, deletions, insertions) in DMPK have not been reported to be associated with DM1. The CTG repeat that is expanded in DM1 lies in the 3' untranslated region of DMPK. Abnormal repeat lengths may reach several thousand, particularly in individuals with congenital DM1. Table 4. Selected DMPK Allelic VariantsView in own windowClass of Variant AlleleDNA Nucleotide ChangeProtein Amino Acid Change Reference SequencesNormalc.*224_226CTG(5-34) 1 (normal range 5-34 CTG repeats)NANM_001081563.1 NP_001075032.1c.*224_226CTG(35-49) 1(normal mutable range 35-49 CTG repeats)Pathologicc.*224_226CTG(50-?) 1(full-penetrance mutant alleles <50 CTG repeats)See Quick Reference for an explanation of nomenclature. GeneReviews follows the standard naming conventions of the Human Genome Variation Society (www.hgvs.org). NA = not applicable1. The CTG variant is in the 3’untranslated region of the gene (indicated by *), with the first nucleotide after the stop codon numbered as *1. Parentheses indicate the range of numbers of the CTG repeats, here indicating normal alleles range from 5-34 repeats. A specific single allele with five repeats would be designated as c.*224_226CTG[5].Normal gene product. Myotonin-protein kinase (DMPK), a 69-kd serine-threonine protein kinase, has been localized to specialized cell structures in heart and skeletal muscle that are associated with intercellular conduction and impulse transmission. It is closely related to cyclic-AMP-dependent protein kinases and to Rho-binding kinases. DMPK may interact with a GTP-binding protein that is a regulatory subunit of myosin phosphatase. Abnormal gene product. The effect of the CTG repeat remains complex and many issues are being clarified [Fiszer & Krzyzosiak 2013]. The effects of an expanded CTG repeat may occur via abnormal RNA transcript processing. Two homologous RNA CUG-binding proteins (CUG-BP and MBNL1 [muscleblind]) have been identified. These proteins are mutually antagonistic mediators of a subgroup of alternative splicing events that are disrupted in DM, in which embryonic forms of some proteins now predominate. These proteins include a chloride channel, resulting in myotonia; the insulin receptor, resulting in increased risk of diabetes mellitus; and microtubule-associated protein tau, encoded by MAPT, a gene associated with cognitive function [Savkur et al 2001, Mankodi et al 2002, Kanadia et al 2003, Ranum & Day 2004, Day & Ranum 2005, Cooper 2006, Leroy et al 2006, Wheeler & Thornton 2007].