J Neurol (2003) 250 : 267–277

DOI 10.1007/s00415-003-0978-3 ENS TEACHING REVIEW

Janet Schmiedel Mitochondrial Cytopathies

Sandra Jackson
Jochen Schäfer
Heinz Reichmann

■ Abstract Mitochondrial cy-
topathies represent a heteroge-
neous group of multisystem disor-
ders which preferentially affect the
Received: 16 September 2002
Accepted: 30 September 2002
Janet Schmiedel, MD () · S. Jackson, BSc,
PhD · J. Schäfer, MD · H. Reichmann, Prof.
Department of Neurology
Carl Gustav Carus University Dresden
Fetscherstr. 74
01307 Dresden, Germany
Tel.: +49-3 51/4 58-46 40
Fax: +49-3 51/4 58-84 57
E-Mail:
Janet.Schmiedel@neuro.med.tu-dresden.de
muscle and nervous systems. They
are caused either by mutations in
the maternally inherited mitochon-
drial genome, or by nuclear DNA-
mutations. Today, approximately
200 different disease causing muta-
tions of mitochondrial DNA
(mtDNA) are known, and due to
the increased knowledge about nu-
clear genetics during the last few
years, more and more nuclear mu-
tations are being described. Owing
to the non-uniform distribution of
mitochondria in tissues and the co-
existence of mutated and wildtype
mtDNA (heteroplasmy) in these or-
ganelles, these disorders may pre-
sent with a huge variety of symp-
toms, even if the same mutation is
involved. Diagnostic investigations
should include the measurement of
serum and CSF lactate, neuroradio-
logical tests and a muscle biopsy to
show the characteristic ragged-red
fibres and cytochrome c oxidase
deficient cells and also to provide
material for genetic analysis. To
date, the treatment of these dis-
eases remains supportive and
should focus on typical complica-
tions such as cardiac dysrhythmia
and endocrinopathy.
■ Key words mitochondrial
cytopathy · respiratory chain ·
mtDNA · ragged-red fibres · lactic
acidosis

from the oxidation of fatty acids, amino acids and pyru-

Introduction
The term mitochondrial cytopathy is used to describe a
number of diseases which have as their root cause a dis-
turbance in one or more of the mitochondrial metabolic
pathways. Each human cell may contain up to a few hun-
dred of these organelles which are essential for aerobic
energy metabolism. Although many fundamental meta-
bolic pathways occur in mitochondria,including the res-
piratory chain, fatty acid β-oxidation and the tricar-
boxylic acid cycle, in this article we will focus on
disorders of oxidative phosphorylation or the respira-
tory chain, which represents the terminal stage in ox-
idative metabolism.
The respiratory chain is composed of five multi-sub-
vate; complex II, or succinate-ubiquinone oxidoreduc-
tase which oxidizes FADH2 derived from the TCA cycle;
complex III, or ubiquinol-ferricytochrome-c oxidore-
ductase; complex IV or cytochrome c oxidase, and fi-
nally, complex V, or ATP synthase. Complexes I, III and
IV pump protons from the mitochondrial matrix into
the intermembrane space, forming an electrochemical
gradient across the inner mitochondrial membrane, and
the energy which this creates is harnessed by ATP syn-
thase for the production of ATP from ADP [33].
Numerous patients with an oxidative phosphoryla-
tion disorder have been described. The deficiency can
involve one (single deficiency) or more (combined defi-
ciency) of the enzyme complexes. Once cellular energy
production falls below a certain threshold in cells with
JON 978

unit enzyme complexes: complex I, or NADH- perturbed oxidative phosphorylation, a compensatory

ubiquinone reductase, which re-oxidizes NADH derived proliferation of all mitochondria, including affected mi-
268
tochondria, occurs. Thus, a typical finding in a muscle
biopsy specimen from a patient with an oxidative phos-
phorylation disorder is an increase of atypical mito-
chondria which stain red with a modified Gomori
trichrome stain, and hence are referred to as ragged-red
fibres (RRF).
Mitochondrial cytopathies show marked clinical het-
erogeneity, involving a range of different symptoms
which are shown in Table 1. This clinical heterogeneity
in part reflects the complex genetics underlying these
disorders and also the fact that tissues with a high en-
ergy demand such as muscle and nerve, are more sus-
ceptible to the decreased energy supply which results
from an oxidative phosphorylation disorder.
A mitochondrial disorder can also develop as a con-
sequence of drug therapy. Zidovudine (AZT), used in
the treatment of patients infected with HIV, can induce
proximal myopathy and RRF [9].
Mitochondrial genetics and DNA mutations
Mitochondria are unique among human cellular or-
ganelles in that they contain their own genome. Every
mitochondrion has several copies of this circular, 16569
basepair encompassing DNA molecule [2], which en-
codes 13 essential proteins of the respiratory chain en-
zyme complexes I, III, IV and V, 22 tRNAs, and 2 riboso-
mal RNAs. All of the other enzymes and factors which
are necessary for mitochondrial DNA transcription,
translation and replication, such as DNA polymerase
and termination factors, are encoded by the nuclear
genome, translated in the cytoplasm and then imported
into the mitochondrion [58].
The mammalian genome has several features which
distinguish it from the nuclear genome, and some of
these features contribute to the pathogenesis of mito-
chondrial disease. First, mtDNA is inherited only from
the mother, as sperm mitochondria are eliminated from
embryonic cells early in embryogenesis by a process
which appears to involve ubiquitination [44, 52]. Thus,
Table 1 Common features of mitochondrial cytopathies
Muscle
Exercise intolerance, hypotonia, proximal myopathy including facial
and pharyngeal muscles, external ophthalmoparesis, ptosis
Heart
Cardiac dysrhythmia, hypertrophic cardiomyopathy
Central nervous system
Optic atrophy, pigmentary retinopathy, myoclonus, dementia, epileptic
seizures, sensorineural deafness, ataxia, stroke-like episodes, mental disorders
Peripheral nervous system
Axonal neuropathy, gastrointestinal dysmotility
Endocrine system
Diabetes, hypoparathyroidism, exocrine pancreatic dysfunction, short stature
mtDNA disease can only be transmitted down the ma-
ternal line. Second, the genetic code of the mitochon-
drial genome differs from that of the nuclear genome
[45]. Third, there are multiple copies of mtDNA in each
cell.A cell or individual is said to be homoplasmic if each
of these copies is identical. If two or more sequence vari-
ants exist in a cell or individual, the condition is referred
to as heteroplasmy. If mutant and normal mtDNA co-ex-
ist in the same cell, respiratory chain function will not be
impaired as long as there is sufficient normal mtDNA to
overcome the effects of the mutant DNA. If, however, the
ratio of mutant to normal mtDNA exceeds a certain crit-
ical threshold, then respiratory chain function will be
impaired. The threshold at which symptoms will mani-
fest depends on the tissue involved. In tissues such as
skeletal muscle, nerve, heart and liver with a high energy
demand, the threshold is lower than in tissues with a low
energy demand. Fourth, mtDNA undergoes continuous
replication, even in non-dividing cells [8]. In patients
with mitochondrial disease this may lead to a change in
the level of heteroplasmy in non-dividing tissues such as
skeletal muscle and nerve if the mutant and wild-type
mtDNA replicate at different rates, and may contribute
to the late onset of symptoms found in some patients.
Fifth, mitochondria are not partitioned equally to
daughter cells during cell division, which can result in
the non-uniform distribution of mutated mtDNA in
these cells. This can result in an individual having com-
pletely different amounts of normal and mutant mtDNA
in different tissues and indeed in the same tissue. Sixth,
mtDNA accumulates mutations more than ten times
faster than the nuclear genome, which has been attri-
buted to a combination of the fact that mtDNA lacks
protective histones, and is in an environment relatively
rich in reactive oxygen species, by-products of the many
metabolic pathways sited in mitochondria, and further
mitochondrial DNA repair mechanisms are inefficient
relative to the nuclear repair mechanisms, although the
latter belief is currently undergoing re-evaluation [61].
Mutations in mtDNA thus accumulate with age, and it is
not unusual to find ragged-red fibres and mtDNA muta-
tions, mostly length variations, in a muscle biopsy spec-
imen from asymptomatic older people [63].
To date, more than 200 different mtDNA changes in
different diseases have been described. These are di-
vided into two groups: point mutations in protein, tRNA,
or rRNA encoding regions, which are often maternally
inherited, and structural rearrangements such as dupli-
cations and deletions, which are usually sporadic.
Nuclear mutations in mitochondrial cytopathies
The respiratory chain complexes are composed of more
than 80 individual polypeptide subunits. Of these, only
13 are mitochondrially encoded, the rest are nuclear en-

coded. In addition, enzymes and other factors necessary
for transcription, replication and translation are im-
ported into the mitochondria from the cell cytoplasm,
and so it is not surprising that nuclear mutations may
lead to disturbances of oxidative phosphorylation. Since
our knowledge of the nuclear genome has increased dra-
matically in the last few years, more and more new nu-
clear encoded defects have been identified.
Today, we distinguish between mutations in struc-
tural proteins and tRNAs which lead to a non-functional
respiratory chain complex, and mutations, which affect
intergenomic communication between the nucleus and
mitochondrion and thus cause secondary mitochon-
drial DNA changes [16, 49]. Such secondary mitochon-
drial DNA changes mainly involve depletions of mtDNA
[34, 38] or multiple mtDNA deletions [20, 23, 51]. In the
main, they follow a Mendelian pattern of inheritance.
Biochemistry
Enzyme histochemical and immunohistochemical
staining of muscle biopsy material is important for both
the diagnosis of mitochondrial diseases and for the elu-
cidation of the pathomechanism of the disease. The
identification of cytochrome-c oxidase (COX) deficient
and succinate dehydrogenase (SDH) positive cells has
proved important in the diagnosis of respiratory chain
disorders [53]. It should be noted, however, that a pro-
found deficiency has to be present in order for the defect
to be detected by these methods.
The activity of the individual respiratory chain com-
plexes can be measured in mitochondria isolated from
tissue biopsy specimen. In tissues with a low level of mu-
tation, however, the enzyme activities may be normal.
Measurement of enzyme activity is also important to es-
tablish that a newly described mutation is disease-caus-
ing.
Diagnostics
Mitochondrial cytopathies are multisystem disorders.
In young patients with a combination of symptoms af-
fecting different tissues, particularly the combination of
progressive proximal myopathy, endocrine dysfunction,
epileptic seizures and cognitive decline, a mitochondrial
cytopathy should be considered. There are also some
characteristic single symptoms, such as progressive ex-
ternal ophthalmoplegia, pigmentary retinopathy com-
bined with other neurological symptoms, or myoclonic
epilepsy with elevated serum lactate levels, which should
lead one to suspect a mitochondrial disease. In infants,
the diagnosis may be very difficult, because they often
present with only one single symptom, muscular hypo-
tonia. Infants who present with hypotonia should there-
269
fore be considered for further investigation of mito-
chondrial function. This is supported by new publica-
tions which show a much higher incidence of mitochon-
drial diseases than was previously thought.According to
Chinnery and Turnbull, 1:50000 of the general popula-
tion is affected with Leber hereditary optic neuropathy
(LHON). In Northern Finland 6.9 % of individuals with
occipital stroke tested positive for the A3243G-MELAS
mutation and 14 % of adults with hypertrophic car-
diomyopathy were carriers of this mutation [10]. It is
now generally assumed that at least 1:8500 individuals
has a mitochondrial disease.
A simple baseline investigation for the diagnosis of
mitochondrial disease is the determination of lactate
and pyruvate levels in blood. In addition, it is helpful to
perform a bicycle ergometer investigation. In a typical
patient with mitochondrial disease, there may be a
pathological increase in serum lactate during physical
exertion. Other clinical investigations such as EMG
(which may show a myopathic pattern) or elevated CSF
lactate and protein are less specific. Typical neuroradio-
logical findings of mitochondrial disease are basal gan-
glia calcifications or stroke-like lesions. Individual find-
ings of the various syndromes are described in the
relevant sections.
The next step of the investigation should include a
muscle biopsy. As already mentioned, RRF are a charac-
teristic feature of a mitochondrial cytopathy. They con-
sist of a subsarcolemmal accumulation of enlarged,
abnormal mitochondria with dense cristae and
paracrystalline inclusions [40]. Ragged-red fibres may,
however, also be found in other diseases such as chronic
polymyositis whilst being absent in some mitochondrial
diseases, such as LHON, in which protein coding genes
are mutated. RRF may also be absent early in the disease
process and in infants with Leigh-like syndromes. Atyp-
ical mitochondria may sometimes be revealed by elec-
tron microscopy, even early in the disease course.
In addition to the verification of ragged-red fibres,
other histochemical and immunological investigations
of the muscle tissue are helpful. These include stains for
cytochrome-c oxidase (COX) and succinate dehydroge-
nase (SDH), and immunohistochemical investigations
using antibodies generated against the individual sub-
units of the respiratory chain complexes. Muscle tissue
provides the possibility for biochemical investigation of
the respiratory chain, as well as material for genetic test-
ing. DNA isolated from blood is frequently used for ge-
netic testing, but because of the continuous turnover of
mitochondria in this tissue, the mutation levels may be
low.
It is therefore preferable to use muscle tissue, partic-
ularly when looking for deletions and duplications. It
should be noted that owing to the different distribution
of mutated DNA in the different tissues a negative result
does not exclude a mtDNA mutation (Table 2).
270
Table 2 Diagnostic investigations in mitochondrial cytopathies
I. Lactate and pyruvate in serum: Check for elevated levels.
II. Exercise testing: Check for abnormally high increase and slow degradation of
serum lactate.
III. Neuroradiological examinations (MRI/CT/SPECT): Calcification of basal gan-
glia? Focal lesions after stroke-like episodes? Cerebral atrophy? Leuken-
cephalopathy?
IV. Muscle biopsy with:
1. Histology: Ragged-red fibres?
2. Histochemistry: COX- negative fibres?
3. Electron microscopy: Enlarged, abnormal mitochondria with dense cristae
and paracrystalline inclusions?
4. Biochemistry: Deficiencies of single complexes of the respiratory chain?
V. Genetic examination (from blood or muscle DNA): Point mutations, deletions,
duplications, depletions?
VI. Additional investigations:
1. Lumbar puncture: Elevated CSF protein or lactate?
2. Electromyography: Myopathic pattern?
3. Electroencephalography: Spikes?
Therapy
No curative therapy is currently available for the treat-
ment of mitochondrial cytopathies. As pharmacological
therapy has proven to be of limited value, as discussed
later in this section, researchers have instead explored
the possibility of gene therapy. One such approach has
involved expressing a wild-type copy of the mutated mi-
tochondrial gene in the nucleus, targeting of the cyto-
plasmically expressed gene product being effected by
means of the inclusion of a mitochondrial targeting pre-
sequence in the engineered gene. This “allotopic” ex-
pression was first used successfully in yeast [25], and,
after many failed attempts, has now been applied
successfully to human cell lines carrying a missense mu-
tation in MTA TP6, the mitochondrial gene encoding
ATPase 6 [29]. A more obvious approach of transfecting
affected mitochondria with wild-type mitochondrial
genes has also been tried [43], however, the exogenous
DNA was neither replicated nor transcribed, and no
practical method of transfecting mammalian mitochon-
dria currently exists.
One of the most promising approaches to gene ther-
apy involves attempts to alter the level of heteroplasmy
by either selectively inhibiting the replication of, or de-
stroying the mutant DNA [48, 54]. Such strategies are
based on the fact that a large copy number of the mutant
mt DNA being required before the effect of the mutation
becomes phenotypically apparent. By effectively reduc-
ing the population of mutant DNA, it is argued that the
propagation of wild-type DNA will occur, resulting in a
normal phenotype.
As there is no cure for mitochondrial diseases, ther-
apy must consist of the prevention and treatment of the
typical symptoms and complications associated with
these diseases. Cardiac complications, particularly car-
diac dysrhythmias, are a prominent feature of many of
the mitochondrial disease syndromes. It has been esti-
mated that 9 % of Finnish and 8 % of Japanese LHON-
patients suffer from pre-excitation syndromes including
Wolff-Parkinson-White and Lown-Ganong-Levine dis-
ease [28, 30], and severe cardiac dysrhythmias are also
very frequent in Kearns-Sayre and MELAS syndromes.
The early implantation of a cardiac pacemaker can be of
great benefit and offer a longer life expectancy to these
patients. MELAS patients often also develop an asymp-
tomatic cardiomyopathy, which responds well to con-
ventional treatment.
Further management includes the use of bicarbonate
and dialysis to correct episodes of severe lactic acidosis.
Endocrine function should be investigated and the ne-
cessary corrective measures initiated. Blood glucose lev-
els should be checked regularly, particularly in individ-
uals with the common 3243 MELAS mutation. Caution
should be exercised in the administration of anticonvul-
sants and anaesthetics [35]. There is evidence that val-
proate inhibits both mitochondrial fatty acid β-oxida-
tion and complex IV, and mitochondrial disease should
be considered as a risk factor for the development of val-
proate-induced liver failure [22].
A variety of agents including antioxidant vitamin
supplements and respiratory chain cofactors have been
used in the past for the pharmacological treatment of
mitochondrial cytopathies, but in spite of subjective and
objective improvements in individual cases, no signifi-
cant effect could be shown in larger trials. Certainly, one
reason for this is the lack of larger double-blind trials
with large cohorts of patients. Patients can be treated
with quinone derivatives, generally with ubiquinone
(coenzyme Q10), taken orally (50–300 mg/day). For this
drug, clinical improvement could be seen in individual
cases, whereas in a multi-centre, double-blind trial no
objective improvement was found [6, 15]. Mashima and
colleagues showed that treatment of LHON-patients
with idebenone (90–270 mg/day) may enhance the rate
and degree of visual recovery [31]. Other agents utilized
in the treatment of patients with respiratory chain de-
fects include thiamine (100–500 mg/day), riboflavin
(50–300 mg/day), which has been used with some suc-
cess in a small number of patients with complex II defi-
ciency, biotin (5–50 mg/day), ascorbic acid (2 g/day), vi-
tamin K (50–150 mg/day) and vitamin E (200–400
IE/day). The therapeutic effectiveness of all of these di-
etary supplements still needs to be proven [32]. Succi-
nate, a respiratory chain substrate which is coupled to
the respiratory chain via complex II, has been used in
patients with complex I deficiency (6 g/day). Further
therapeutic possibilities include creatine (up to
10 g/day), and L-carnitine (3 g/day) has been used in
those patients with a secondary carnitine deficiency.
Our lack of knowledge about the proportion of mu-

tated DNA which is necessary to produce disease symp-
toms, the random distribution of mtDNA into different
tissues, and the marked clinical heterogeneity displayed
by mtDNA transmitted disorders hampers our ability to
provide genetic counseling and prenatal diagnosis. It is
not yet clear to what extent the levels of mutation load
determined in chorionic villus samples compare with
those in the fetus. There have been some attempts made
to get more information about the prenatal risk using
data from mouse models and studies involving human
oocytes [37, 56, 64].
Mitochondrial syndromes
■ External Ophthalmoplegia (CPEO/PEO),
Ophthalmoplegia plus syndrome
and Kearns-Sayre syndrome (KSS)
Symptoms
CPEO, PEO, Ophthalmoplegia plus and Kearns-Sayre
syndrome share many common clinical features which
makes the differential diagnosis of these syndromes dif-
ficult. External ophthalmoplegia is characteristic for all
of these disorders. If only this symptom occurs, the syn-
drome is referred to as progressive external ophthalmo-
plegia (PEO) or chronic progressive external ophthal-
moplegia (CPEO). In Kearns-Sayre syndrome the
patients are more severely affected with onset of the dis-
ease before the age of 20 years. The prominent features
of KSS are retinopathy, proximal muscle weakness, car-
diac arrhythmia and ataxia [21]. If onset is after the age
of 20 or any of these four symptoms are missing, the dis-
ease is referred to as ophthalmoplegia-plus-syndrome.
The muscular weakness affects the facial, pharyngeal,
trunk and shoulder muscles in particular, leading to
dysarthria and dysphagia in many patients. Some pa-
tients may even become malnourished. Other common
features are small stature, deafness, dementia, delayed
puberty and endocrine dysfunction, especially diabetes.
MRI findings differ from patient to patient; common
findings are leukencephalopathy or basal ganglia calci-
fications. The clinician should pay particular attention
to any cardiomyopathy and cardiac arrhythmia. During
recent years, the early implantation of a cardiac pace-
maker has been shown to extend the life expectancy of
patients with KSS.
Investigations
In approximately 50 % of patients there is a demonstra-
ble increase in blood lactate at rest and/or during exer-
cise testing. CSF protein and lactate are usually elevated.
A muscle biopsy is always recommended for histological
examination and to provide material for molecular ge-
271
netic testing. If the diagnosis is confirmed a regular car-
diological follow-up should be carried out so that any
cardiac arrhythmias which may develop, can be treated
at an early stage. Surgical correction of impairing ptosis
is possible, but the benefits are usually transient.
Biochemistry
A deficiency of cytochrome-c oxidase (COX) can often
be shown by measurement of the enzyme activity in ho-
mogenates of affected muscles. Single COX-negative fi-
bres, usually corresponding to ragged-red fibres, can be
demonstrated histochemically.
Genetics
The majority of cases are sporadic, although more rarely
familial cases do occur, which can be maternally or au-
tosomally inherited. In almost 80 % of patients with
Kearns-Sayre syndrome a heteroplasmic deletion of
mtDNA can be identified. 50 % of CPEO-patients have
such a deletion (Fig. 1), [18]. The most frequently iden-
tified deletion, the so-called “common deletion”, in-
volves 4977 nucleotides and is usually flanked by small,
identical DNA-sequences (direct repeats). Duplications
of the mitochondrial genome can cause symptoms sim-
ilar to mtDNA deletions, but are much rarer. The exis-
tence of multiple mtDNA deletions together with auto-
somal inheritance is characteristic of an underlying
nuclear mutation, which is typical for PEO [19]. The re-
maining patients probably have unidentified mutations
in either the nuclear or mitochondrial genome.
Fig. 1 Characteristic Southern blot with wild-type and deleted mitochondrial
DNA. The smaller deleted DNA molecules (bottom band) move further down the
agarose gel than the larger wild-type ones. Deletions are heteroplasmic; even pa-
tients with a deletion have some mitochondrial DNA, which is of normal length (top
band). The DNA in lanes 1, 3, 5, 7 and 9 was digested with the restriction endonu-
clease BamHl and that in lanes 2, 4, 6, 8 and 10 with Pvu II. Lanes 5 and 6 show wild
type DNA. Lanes 1 and 2 show DNA from a patient with a deletion, Lanes 9 and 10
show DNA from a patient with multiple deletions. Lanes 3, 4 and 7, 8 show DNA
from a patient with a polymorphism. This polymorphism produces a new Pvu II re-
striction site, whereas the DNA which was digested with BamHl remains uncut.
272
■ Myoclonic epilepsy associated
with ragged red fibres (MERRF)
Symptoms
MERRF is a chronic neurodegenerative disease, usually
starting in the 2nd or 3rd decade of life. It is maternally in-
herited and severely affected individuals develop a typ-
ical combination of symptoms consisting of myoclonic
epilepsy and ragged-red fibres in muscle. In addition,
patients often present with myoclonus, dementia, car-
diomyopathy, pyramidal tract signs, neuropathy, optic
nerve atrophy and neurosensory hearing loss. There are
some case reports indicating that cardiac dysrhythmias
are also a common feature in this syndrome [1]. Similar
to other mitochondrial diseases, the neurological symp-
toms in affected families are extremely variable.
Investigations
Very often serum and CSF pyruvate and lactate levels are
elevated. Serum creatine kinase may also be raised. Elec-
tromyography may show a myopathic pattern. Epileptic
discharges may be found on EEG.CT and MRI mostly re-
veal a general cerebral atrophy. Ragged-red fibres are a
hallmark of this disease.
Biochemistry
Biochemically, the mutation produces multiple deficien-
cies in the enzyme complexes of the respiratory chain,
most prominently involving NADH-CoQ reductase
(complex I) and cytochrome-c oxidase (COX) (complex
IV), consistent with a defect in the translation of all
mtDNA-encoded genes [5, 62].
Genetics
To date, three different mtDNA point mutations,
A8344G, T8356C and G8363A, have been identified as
causal for this syndrome.All of these mutations reside in
tRNALys, and approximately 80 % of affected individuals
carry the A8344G mutation in heteroplasmic form [45].
The other two mutations are much rarer [36, 46]. Trans-
fer of mitochondria harbouring a point mutation in tR-
NALys to cells lacking mtDNA has confirmed the muta-
tion as disease causing [11].
■ Mitochondrial myopathy, encephalopathy,
lactic acidosis and stroke-like episodes (MELAS)
Symptoms
MELAS is one of the most frequently occurring mito-
chondrial diseases. It is usually maternally inherited.
Clinical symptoms are highly variable in affected pa-
tients. Distinctive features involve short stature, hearing
loss and diabetes. The prevalence of diabetes due to the
A3243G mutation has been estimated at 0.06 % of the
general population [14]. In addition to these symptoms,
patients often complain of episodic migraine-like
headaches with vomiting. Stroke-like episodes are the
prominent feature of this disease. They are attributed to
a failure of mitochondrial energy metabolism rather
than to a vascular ischaemia [26]. Topically,occipital and
temporal cortical regions are primarily affected, leading
to hemianopia or hemiparesis. During the course of the
disease,patients may develop a myopathy of facial,trunk
and limb muscles with excessive fatigue, ophthalmo-
paresis, ataxia and cardiomyopathy. Endocrine dysfunc-
tion is very common and affects the hypothalamic-pitu-
itary axis and the thyroid as well as the pancreas. The
clinical picture of MELAS, KSS and CPEO may be very
similar. This is of particular importance when under-
taking genetic investigations.
Investigations
Lactic acidosis is common and may increase substan-
tially with exercise. Occipitally located strokes can aid in
the diagnosis, as well as bilateral basal ganglia calcifica-
tions (Fig. 2), [5]. Other abnormalities include cerebellar
and cerebral atrophy. Electromyography may show a
myopathic pattern in affected muscles, electroen-
cephalography can also be pathological. Typically, RRF
are present in a muscle biopsy. In contrast to KSS, where
the mutation can only be detected in muscle, diagnosis
can be made from muscle and blood.
Fig. 2 MRI of a nine-year old MELAS patient (T1-weighted with contrast and T2-
weighted). The discrete swelling, eventually leading to tissue atrophy (and not
necrosis), is a characteristic finding. The location of the lesions does not correspond
to the territories of the arterial blood supply (with the kind permission of Prof. v.
Kummer, Dpt. of Neuroradiology, Dresden).

Biochemistry
MELAS-patients show a reduced activity of complex I
and cytochrome-c oxidase (COX).
Genetics
An A to G transition at nucleotide position 3243 of the
mitochondrial genome in the gene for tRNALeu accounts
for 80 % of MELAS cases. Mutations at position 3250 and
3252, also in tRNALeu, have also been described. The dis-
ease can manifest with apparently low percentages of
mutation, with onset being described in cases with a
level of 4 % mutant DNA in blood cells, 38 % in skeletal
muscle and 41 % in cultured skin fibroblasts [13]. In se-
vere cases, the mutation load in brain and muscle may
be as high as 80 % or more.
■ Leber hereditary optic neuropathy (LHON)
Symptoms
This disease typically manifests as subacute bilateral
blindness in young men. Both eyes can be affected si-
multaneously or sequentially with an average interval of
2 months. On fundoscopy, patients, and sometimes their
asymptomatic maternal relatives, may show peripapil-
lary telangiectasia, microangiopathy, disc pseudoedema
and vascular tortuosity. The disease results in a central
scotoma and does not respond to medication. The final
visual acuity can range from 20/50 to no light percep-
tion, with the less severe mutations having less severe
outcomes. The majority of LHON patients do not suffer
from additional neurological symptoms. There are some
exceptions, however, and common ancillary symptoms
are cardiac conduction defects, altered reflexes, ataxia,
sensory neuropathy, skeletal abnormalities and dystonia
[27]. Furthermore, there is an above-average incidence
of multiple sclerosis in patients and their relatives [60].
Approximately 9 % of LHON patients suffer from car-
diac arrhythmia (mainly from pre-excitation syn-
dromes, including Wolff-Parkinson-White and Lown-
Ganong-Levine disease), which is of particular
importance for their treatment.
Investigation
In some cases serum lactic acidosis is present. The ten-
tative diagnosis is made on the basis of the ophthalmo-
logical symptoms and can be confirmed by genetic and
biochemical investigations. The mutation analysis is
usually made in blood DNA. In view of possible cardiac
complications, regular cardiac follow-up examinations
should be performed.
273
Biochemistry
Histochemically, there is an absence of ragged-red fi-
bres, despite a biochemically demonstrable deficiency of
complex I.
Genetics
Penetrance is often incomplete in LHON families, and
males are affected more often than females. This incom-
plete penetrance suggests that secondary factors are
necessary for the manifestation of the optic neuropathy.
To date, approximately 25 mtDNA variants have been
found in LHON patients. These are divided into primary
mutations, which are high risk factors for the develop-
ment of LHON, and secondary mutations, which al-
though associated with the disease have not been as-
cribed a causative role in its development. Amongst the
primary mutations, the most important is a missense
mutation at position 11778 of the mtDNA. This muta-
tion, which is in subunit 4 of complex I, accounts for the
majority of LHON cases in the Caucasian race and is
usually homoplasmic, although it may be detected in
heteroplasmic form in asymptomatic relatives. Other
primary mutations include those at positions 3460, 4160
and 14484 of the mitochondrial genome.
■ Leigh syndrome (infantile subacute necrotizing
encephalopathy) and NARP (neuropathy,
ataxia and pigmentary retinopathy)
Symptoms
Leigh syndrome is a progressive neurodegenerative dis-
ease which usually affects infants, but has also been de-
scribed in adults. In infants, the disease first manifests
with failure to thrive, developmental delay and loss of
developmental milestones. Clinical symptoms include
perinatal asphyxia, respiratory dysfunction, cranial
nerve dysfunction, ataxia, dystonia, muscle weakness
and lactic acidosis. The disease course is usually un-
remitting. Frequently, death occurs during the first years
of life.
NARP syndrome is composed of axonal neuropathy,
limb and gait ataxia and pigmentary retinopathy. Gen-
erally it manifests in the 2nd decade of life and pro-
gresses much more slowly than Leigh syndrome. Addi-
tional symptoms are dementia and seizures.
Investigations
In both syndromes lactic acid is elevated in blood and
cerebrospinal fluid. In Leigh syndrome the characteris-
tic neuroradiological features are bilateral symmetric
lesions in the MRI, which involve medulla oblongata,
274
mesencephalon, aqueduct, cerebellum and the basal
ganglia. In contrast, NARP-patients often only show
cerebellar and olivopontocerebellar atrophy. During life,
a diagnosis of Leigh syndrome can only be confirmed by
genetic analysis and/or measurement of enzyme activ-
ity. The genetic analysis can be carried out in muscle and
blood. At autopsy, the main pathology is gray matter de-
generation with foci of necrosis and capillary prolifera-
tion in the brain stem and other affected brain areas.
Whilst in Leigh syndrome the muscle biopsy frequently
shows no RRF, these are more often demonstrated in
NARP.
Biochemistry
This syndrome has been attributed to both deficiency of
cytochrome-c oxidase and complex I of the respiratory
chain, as well as to defects in other enzymes involved in
energy metabolism, for example pyruvate dehydroge-
nase and pyruvate decarboxylase.
Genetics
Leigh syndrome can be transmitted by different modes
of inheritance: X-linked recessive, autosomal recessive
and mitochondrial. The typical mitochondrial point
mutation is situated at position 8993 in the ATPase 6-
gene. If the mutation level is above 90 % patients suffer
from Leigh disease. Patients in whom the mutation load
is between 70 % and 90 % develop a NARP syndrome
[55]. Individuals with less than 70 % of the point muta-
tion can be asymptomatic. The X-linked [4] and autoso-
mal recessive forms of the disease are rarer than the
mtDNA transmitted form. In recent years, a number of
novel nuclear mutations which give rise to Leigh syn-
drome have been described [24, 47, 57, 59, 67].
■ Other mitochondrial syndromes
Familial aminoglycoside-induced progressive sen-
sorineural deafness is caused by a 12S ribosomal RNA
mutation at position 1555. Since the pharmacological
target of aminoglycosides is the bacterial ribosome, the
evolutionary related mitochondrial ribosomes are the
most likely site of aminoglycoside ototoxicity. The syn-
drome was first described by Prezant et al. [39] in a large
Arab-Israeli kindred. Patients homoplasmic for the
point mutation A1555G can develop rapidly progressive
hearing impairment resulting in deafness, during treat-
ment with aminoglycosides. Hearing impairment or
deafness can, however, occur independent of antibiotic
treatment in individuals harbouring this mutation [12].
Pearson syndrome is characterised by a refractory
sideroblastic anaemia in neonates with vacuolization of
the haemopoietic precursor cells. Clinically, patients
present with exocrine pancreatic dysfunction, some-
times accompanied by lactic acidosis. Both sexes are af-
fected equally. Repeated blood transfusions are neces-
sary and often this disease leads to death in infancy.
Interestingly, in children who survive the first years of
life, a normalisation of the haematological and pancre-
atic function occurs. The patients,however,then develop
the clinical signs of Kearns-Sayre Syndrome and/or a
mitochondrial encephalomyopathy [65]. Genetic analy-
sis shows mitochondrial DNA deletions in blood and in
bone marrow [42].
Wolfram syndrome (DIDMOAD) is a rare disease nor-
mally inherited in an autosomal recessive manner. The
patients develop the disease in infancy and suffer from
diabetes mellitus, diabetes insipidus, optic atrophy and
deafness. In some cases, mtDNA-deletions have been de-
scribed, in other cases some of the so-called secondary
LHON mutations have been identified [17, 41].A nuclear
mutation on chromosome 4 has recently been described
[3, 7, 17].
The mitochondrial neurogastrointestinal en-
cephalopathy (MNGIE syndrome) is a multisystem dis-
order with onset between the second and fifth decade.
Patients present with ptosis, progressive external oph-
thalmoplegia and a characteristic gastrointestinal dys-
motility, often with pseudo-obstruction and malabsorp-
tion resulting in chronic malnutrition. Ancillary
symptoms include diffuse leukencephalopathy, low
body weight, peripheral neuropathy and myopathy. Mul-
tiple mtDNA-deletions were detected in some patients,
indicating an autosomal pattern of inheritance. Proba-
bly the multiple mitochondrial deletions result from a
dominant nuclear mutation [66].
Most patients suffering from mitochondrial depletion
syndrome are normal at birth. Symptoms manifest in the
early neonatal period with prominent congenital my-
opathy, hypotonia and weakness of the limb muscles, as
well as progressive kidney and liver failure, cardiomy-
opathy, lactic acidosis and epileptic seizures. The chil-
dren usually die in the first year of life, but the disease
course can be slower. Ragged-red fibres can be seen in
the muscle biopsy specimen. In affected tissues a
marked reduction of mtDNA (up to 98 %) can be found,
although a mtDNA-mutation cannot be detected [34].
Affected tissues have variable levels of mtDNA deple-
tion, whilst unaffected tissues have normal levels of
mtDNA.
Conclusion
Mitochondrial cytopathies are multisystem disorders
caused by either mitochondrial or nuclear mutations.
Owing to the enormous variability of the clinical symp-
toms extensive diagnostic investigations, including
measurement of serum and CSF lactate, exercise testing
 275

and neuroradiological examinations, are required. A For further information:

muscle biopsy is usually necessary to confirm the diag-
nosis and to provide suitable material for biochemical
and genetic analysis. Typical histochemical findings are
ragged-red fibres, cytochrome (COX)-negative fibres
and abnormal succinate dehydrogenase (SDH)-staining.
For lack of a causative treatment, current therapeutical
approaches consist of prevention and/or treatment of
disease complications (e. g. epilepsy, cardiomyopathy,
diabetes) and administration of various respiratory
chain cofactors and vitamins. The prevention of cardiac
and endocrine complications is essential for the better
prognosis of these disorders.
Today, the treatment of mitochondrial cytopathies is
restricted to symptomatic measures. Given the recent
advances in molecular biology and medicine, we hope
that significant progress in the understanding of basic
disease mechanisms will lead to new therapy options for
these rare disorders.
 Centre for Inherited Disorders of Energy Metabolism
http://www.cwru.edu/med/CIDEM/cidem.htm
 Forschungsgruppe für mitochondriale Genetik
http://www.mitogen.de
 MitBASE: A comprehensive and integrated mito-
chondrial DNA database http://www3.ebi.ac.uk/Re-
search/Mitbase/mitbase.pl
 MITOMAP: A human mitochondrial genome data-
base http://www.gen.emory.edu/mitomap.html
 The Mitochondrial Medical Society
http://www.mitosoc.org/
 The Mitochondria Research Society
http://www.mitoresearch.org/

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