X-LINKED DOMINANT CHARCOT-MARIE-TOOTH NEUROPATHY: ANALYSIS OF A PEDIGREE WITH A NOVEL MUTATION OF CONNEXIN 32

Objective: To report a family with X-linked Charcot-Marie-Tooth neuropathy (CMTX) with a novel mutation of connexin 32 (Cx32).
Background: Cx32, a gap-junction protein, is expressed in various neural and non-neural tissues. In the peripheral nervous system (PNS), Cx32 is expressed by the Schwann cell and it is believed to form reflexive gap-junctions at the Schmidt-Lantermann incisures and paranodes; in the central nervous system, Cx32 is expressed by neurons and oligodendrocytes. Mutations of Cx32 causes an apparently tissue-specific disorder of PNS: CMTX.
Methods: We examined, clinically and electrophysiologically, 2 brothers with CMT and their asymptomatic mother. We performed a sural nerve biopsy in the 29-year-old proband and analysed the Cx32 gene (GJB1) by direct nucleotide sequencing.
Results: We detected a novel GTA→GAA of GJB1 that is predicted to cause a Val23Glu substitution in the first transmembrane domain of Cx32. NCV studies disclosed features of a demyelinating neuropathy in the severely-affected hemizygous brother, and slowing of the sensory conduction velocity in the sural nerve in the mother who showed pes cavus and areflexia. In all three examined patients, BAEPs showed both delayed wave 1 and prolonged interpeak-latency-time (IPL I-V); central motor conduction time by MEPs was normal. The nerve biopsy in the proband was consistent with a primary axonal degeneration.
Conclusions: Cx32 mutations may lead also to a dysfunction of the CNS. Electrophysiological abnormalities of the CNS pathways may orientate the diagnosis of CMT towards Cx32.     

A novel Cx32 mutation causes X-linked Charcot-Marie-Tooth disease with brainstem involvement and brain magnetic resonance spectroscopy abnormalities

Abstract The objective of this study was to study genetic and phenotypic features of a family with X-linked Charcot-Marie-Tooth consisting of a healthy father, affected mother, two affected sons and one healthy one. A detailed electrophysiological and neuroimaging study, along with sequencing of the Cx32 gene, was performed in all family members. A novel Cx32 123 G>C mutation, determining an aminoacid variation (Glu41Asp), was found in the mother and the affected sons. An alteration in brainstem evoked potentials was found in the mother and one affected son. The affected son, who underwent magnetic resonance imaging, showed symmetrical hyperintensities in paratrigonal white matter, not found in his heterozygous mother, while both subjects exhibited alterations in brain metabolite ratios derived from localised proton-magnetic resonance spectroscopy. These data extend previous findings about central nervous system involvement in Cx32 mutated subjects and further support a functional role of the protein expression in oligodendrocytes.     

腓骨肌萎缩症X型临床、电生理及Connexin 32新突变一例

目的报告1例X连锁型腓骨肌萎缩症(CMTX),探讨其临床表现、电生理特点和连接蛋白32(Cx32)基因突变特点。方法对1例临床诊断CMT患者进行详细的病史采集和临床查体,分析其电生理和神经活检检查结果,同时进行周围髓鞘结构蛋白22(PMP22)基因重复和Connexin32(Cx32)基因突变检测。结果患者临床表现为经典的遗传性感觉运动神经病,肌电图检查提示脱髓鞘损害伴轴索损害,同时出现传导阻滞;神经活检示脱髓鞘性周围神经损害;基因检测发现Cx32基因编码序列第414位碱基发生单碱基错义突变(414C>G),造成其编码的第138位的氨基酸由丝氨酸突变为精氨酸(Ser138Arg)。结论 414C>G突变为Cx32基因新突变,国内外文献未见报道。该基因型没有产生特殊的临床表现,但电生理表现为脱髓鞘为主的混合性周围神经病变,且具有传导阻滞的特点。Cx32基因不同的突变位点和形式可能是导致CMTX临床异质性的原因之一。     

Novel 95G>A (R32K) somatic mosaic connexin 32 mutation

Charcot-Marie-Tooth disease (CMT) is among the most common inherited disorders of the peripheral nervous system, and it is broadly categorized as demyelinating type 1 or axonal type 2 based on nerve conduction studies. Mutations in discrete genes usually segregate into a single phenotype. However, mutations in connexin 32 (Cx32) can produce both axonal and demyelinating CMT phenotypes. Although over 300 mutations have been described in Cx32, somatic mosaicism has only been reported once previously. We report a 39-year-old man who was referred for electrodiagnostic evaluation due to a history of bilateral carpal tunnel syndrome. His physical examination and electrodiagnostic findings demonstrated a mild sensorimotor axonal peripheral neuropathy. Sequencing of his Cx32 (GJB1) gene identified a guanine-to-adenine (G>A) transition at nucleotide position 95. This transition mutation involved approximately one-third of leukocyte-derived genomic DNA. This is the second reported case of somatic mosaicism, and it highlights the phenotypic diversity among CMTX patients.     

X连锁腓骨肌萎缩症Cx32基因的突变、临床和电生理特点

目的 分析X连锁腓骨肌萎缩症（CMTX）患者Cx32基凶的突变及其临床表现和电生理特点、方法应用多聚酶链反应一单链构象多态性分析结合DNA直接测序的方法,对24例无周围髓鞘蛋白（PMP）22基因大片段重复突变,家系中无男传男的腓骨肌萎缩症（CMT）先证者进行Cx32基因的突变分析;对先证者及其家系内患者进行临床和电生理检查。结果 在6个X连锁遗传家系和1例散发患者中发现了7个不同的Cx32基因突变,其中4个家系临床分型为CMTI型,2个家系为CMT中间型,散发病例为CMT1型检测到有Cx32基因突变的家系成员共38例,其巾男性20例,全部为CMTX患者;女性18例,其中6例为CMTX患者,12例为无临床症状的携带者;26例患者均为周围神经轻、中度受累。结论 CMTX的遗传方式可为X连锁显性、X连锁隐性遗传,也可为散发。根据临床和电生理特点分为CMTI型或CMT中间型,多为周围神经轻、中度受累,男性患者的症状通常较女性重。在没有检测到PMP22基因大片段重复突变和无男传男的CMT家系中应首先进行Cx32基因突变分析。     

Abnormalities in the axonal cytoskeleton induced by a connexin32 mutation in nerve xenografts

The X-linked form of Charcot-Marie-Tooth neuropathy is associated with mutations in the connexin32 (Cx32) gene. The functional role of Cx32 in Schwann cells and the relationship of these mutations to the progressive axonal loss and distal limb weakness seen in this disease have not been elucidated. To investigate the local influence of Schwann cells bearing the Cx32 gene defect on axonal cytoskeleton and the myelination process, the nerve xenograft model was used to transfer a Cx32 missense mutation (Glu102Gly) from human to an in vivo myelination system in nude mice. Twelve nerve grafts from two family members with Cx32 mutations and 17 grafts from three healthy individuals were generated by end-to-end anastomosis of approximately 6-mm sural nerve fascicles into the cut ends of the sciatic nerve in nude mice. Specimens were examined at 2, 4, 8, 12, and 16 weeks. Ultrastructural morphometric analysis showed Schwann cells with Cx32 mutation have a profound effect on the nude mice axons, resulting in an increase in neurofilament density, a depletion of microtubules associated with fragmentation of smooth axonal reticulum, and increased vesicles and mitochondria. At 16 weeks, axonal enlargement was evident within the proximal part of the graft; axonal atrophy, degeneration, and fiber loss were seen in distal-graft and host segments. The myelination process was not affected. We conclude that Cx32 mutation impairs a modulatory function of Schwann cells on axons, resulting in profound cytoskeletal alterations leading to distal axonal degeneration. These observations emphasize the role of impaired Schwann cell-axon interactions in the pathogenesis of hereditary neuropathies. J. Neurosci. Res. 51:174–184, 1998. © 1998 Wiley-Liss, Inc.     

Six novel connexin32 (GJB1) mutations in X-linked Charcot-Marie-Tooth disease

X-linked Charcot-Marie-Tooth disease (CMTX) is a clinically heterogeneous hereditary motor and sensory neuropathy with X-linked transmission. Common clinical manifestations of CMTX, as in other forms of Charcot-Marie-Tooth disease (CMT), are distal muscle wasting and weakness, hyporeflexia, distal sensory disturbance, and foot deformities. Motor nerve conduction velocity is reduced. In male patients it is often less than 38 m/s in the median nerve (a value often used to distinguish between "demyelinating" and "axonal" forms of CMT), but in female patients conduction velocity may be faster than this or normal. Mutations in the connexin32 (gap junction protein beta 1 (GJB1)) gene are responsible for the majority of CMTX cases. This report describes six British CMTX families with six novel mutations (four missense, one nonsense, and one frame shift) of the GJB1 gene. Affected members in these six families had typical signs of CMT but in some affected members of three families there was additional central nervous system involvement or deafness in the absence of any other explanation other than CMT.     

Clinical and molecular studies in a family with probable X-linked dominant Charcot-Marie-Tooth disease involving the central nervous system.

OBJECTIVE: To investigate the clinical and molecular characteristics of an apparently X-linked dominant form of Charcot-Marie-Tooth (CMT) disease in a family with central nervous system involvement and additional features. BACKGROUND: Charcot-Marie-Tooth disease may be inherited as an autosomal dominant, autosomal recessive, or X-linked trait. In the X-linked dominant form of CMT, females demonstrate milder clinical and electrophysiological features compared with their male relatives. METHODS: Clinical and related examinations were performed in 4 affected individuals from a family with a novel form of CMT affecting males more severely than females. DNA analysis of the connexin 32 (Cx32) gene and proteolipid protein (PLP) gene was performed. We genotyped 3 members of the family to determine which regions of the X chromosome were inherited discordantly in the affected and unaffected brothers. RESULTS: Clinical studies revealed significant spasticity, hyperreflexia, and delayed central conduction, in addition to peripheral neuropathy. Nerve conduction velocities were slower in the affected males than in the affected females. Direct DNA sequencing of the Cx32 coding region and neural-specific promoter were normal. A PLP null mutation was excluded. Levels of very long chain fatty acids were normal. Genotyping studies of the X chromosome supported X-linked inheritance of the neuropathy. CONCLUSIONS: This family differs from others with hereditary motor and sensory neuropathic diseases by the presence of upper motor neuron signs and additional features. The clinical features and inheritance pattern are consistent with X-linked dominant inheritance or autosomal dominant inheritance.     

The effects of a dominant connexin32 mutant in myelinating Schwann cells

Mutations in GJB1, the gene encoding the gap junction protein connexin32 (Cx32), cause X-linked Charcot-Marie-Tooth disease, an inherited demyelinating peripheral neuropathy. We generated transgenic mice that express the R142W mutation in myelinating Schwann cells. The R142W mutant protein was aberrantly localized to the Golgi, indicating that it does not traffic properly, but the molecular organization of the myelin sheath, including the localization of Cx29, another connexin expressed by myelinating Schwann cells, was not disrupted. In a wild type background, this mutation dramatically decreased the level of wild type mouse Cx32 in immunoblots of sciatic nerve and caused demyelination. The expression of wild type human Cx32 with the same transgenic construct had different effects-increased amounts of Cx32, normal localization of Cx32 at nodes and incisures, and split myelin sheaths. Thus, the R142W mutant protein has dominant effects that are distinct from overexpression.     

Vocal cord paresis and probable X-linked Charcot-Marie-Tooth disease with novel GJB1 mutation

We describe a Chinese family with a probable X-linked dominant inherited disorder characterized by early adult onset of distal muscle weakness and amyotrophy of four limbs, followed by severe disability of feet. The life expectancy of some patients is decreased due to severe respiratory failure associated with bilateral vocal cord involvement. The electrophysiological data showed predominantly the evidence of demyelization. Genetic analysis revealed that all tested patients from the family carried a novel c.186C>G mutation in the GJB1 gene, resulting in substitution of Serine for Arginine in the first extracellular loop domain of Cx32 protein. To our knowledge, this is the first time to describe this GJB1 mutation, which is associated with the rather severe phenotype of the X-linked Charcot-Marie-Tooth disease. The present report also provides further evidence for heterogeneity among the X-linked Charcot-Marie-Tooth disease.     

Charcot-Marie-Tooth neuropathy: clinical phenotypes of four novel mutations in the MPZ and Cx 32 genes

Charcot-Marie-Tooth Hereditary Neuropathy is a heterogeneous syndrome associated with mutations in several different genes including peripheral myelin protein 22, myelin P0, connexin 32, and early growth response 2. There is considerable variability in the phenotypic expression of this syndrome and the relationship of this variability to mutation genotypes requires extensive analysis. Here we describe the phenotypes and genotypes of four new mutations underlying the Charcot-Marie-Tooth syndrome and document segregation with disease. Four families with Charcot-Marie-Tooth were ascertained, examined, and evaluated electrophysiologically. Each family had peripheral blood DNA screened for mutations in myelin protein 22, myelin P0, and connexin 32. Two families were found with new mutations in the myelin P0 gene: S140T in the extracellular domain and K236del in the cytoplasmic domain. All families showed segregation of the mutations with the Charcot-Marie-Tooth phenotype as did a new family with the rare G163R mutation in the membrane domain. A 49-year-old man with the S140T mutation demonstrated conduction block on electrophysiological testing. A family with a novel S49P mutation in the connexin 32 gene had a neuropathy with very slow nerve conduction. These new mutations in the myelin P0 and connexin 32 genes help to clarify the pathophysiology of the clinical Charcot-Marie-Tooth syndrome. The S140T mutation in myelin P0 can be associated with conduction block and Charcot-Marie-Tooth should be part of the differential diagnosis of that phenomenon. Mutations in the cytoplasmic domain of myelin P0 can cause clinical neuropathy. The S49P mutation in the connexin 32 gene can produce aspects of a demyelinating type of X-linked hereditary neuropathy.     

Central visual, acoustic, and motor pathway involvement in a Charcot-Marie-Tooth family with an Asn205Ser mutation in the connexin 32 gene

BACKGROUND: X linked dominant Charcot-Marie-Tooth disease (CMT1X) is an inherited motor and sensory neuropathy that mainly affects the peripheral nervous system. CMT1X is associated with mutations in the gap junction protein connexin 32 (Cx32). Cx32 is expressed in Schwann cells and oligodendrocytes in the peripheral (PNS) and in the (CNS) respectively. METHODS: A CMT1X family with a Cx32 mutation was examined clinically and electrophysiologically to determine whether PNS, or CNS, or both pathways were affected. RESULTS: In a CMT1X family a novel mutation (Asn205Ser) was found in the fourth transmembrane domain of Cx32. The patients showed typical clinical and electrophysiological abnormalities in the PNS, but in addition visual, acoustic, and motor pathways of the CNS were affected subclinically. This was indicated by pathological changes in visually evoked potentials (VEPs), brainstem auditory evoked potentials (BAEPs), and central motor evoked potentials (CMEPs). CONCLUSIONS: These findings underscore the necessity of a careful analysis of CNS pathways in patients with CMT and Cx32 mutations. Abnormal electrophysiological findings in CNS pathway examinations should raise the suspicion of CMTX and a search for gene mutations towards Cx32 should be considered.     

Cellular mechanisms of connexin32 mutations associated with CNS manifestations

Both oligodendrocytes and myelinating Schwann cells express the gap junction protein connexin32 (Cx32). Mutations in the gene encoding Cx32 (GJB1) cause the X-linked form of Charcot-Marie-Tooth disease (CMTX). Although most CMTX patients do not have clinical central nervous system (CNS) manifestations, subclinical evidence of CNS dysfunction is common. We investigated the cellular effects of a subgroup of GJB1/Cx32 mutations that have been reported to cause clinical CNS dysfunction. We hypothesized that these mutants have dominant-negative effects on other connexins expressed by oligodendrocytes, specifically Cx45. We expressed these and other Cx32 mutants in communication-incompetent as well as Cx45-expressing HeLa cells, and analyzed the transfected cells by immunocytochemistry and immunoblotting. In communication-incompetent cells, the mutants associated with CNS phenotypes failed to reach the cell membrane and were instead retained in the endoplasmic reticulum (A39V, T55I) or Golgi apparatus (M93V, R164Q, R183H), although rare gap junction plaques were found in cells expressing M93V or R183H. In HeLa cells stably expressing Cx45, these Cx32 mutants showed a similar expression pattern, and did not alter the pattern of Cx45 expression. These results indicate that Cx32 mutants that are associated with a CNS phenotype do not interact with Cx45, but may instead have other toxic effects in oligodendrocytes.     

Clinical phenotype in X-linked Charcot-Marie-Tooth disease with an entire deletion of the connexin 32 coding sequence

To clarify the clinical phenotype and molecular mechanism in X-linked Charcot-Marie-Tooth disease (CMTX) patients with a deletion of the whole connexin 32 (Cx32) coding sequence, we studied a family with this deletion by electrophysiology, Southern blotting and quantitative PCR analyses. Two brothers with no copy of Cx32, 27 and 25 years old, showed steppage gait, moderate muscle atrophy and weakness, and mild sensory disturbance in the distal parts of the legs. The clinical phenotypes in these brothers were not different from those in patients with other types of severe Cx32 mutations. Their mother, with one copy of Cx32, showed very mild muscle weakness and sensory disturbance. An electrophysiological study showed a nonuniform demyelinating neuropathy with some aspects of an axonal-loss neuropathy. Sural nerve biopsy showed loss of myelinated fibers, many relatively thin myelin sheaths, clusters of small myelinated fibers, and some onion bulb formations. The present findings suggest that both a demyelinating process and an axonal involvement were present in the patients with total defect of Cx32 probably due to loss of the function mechanism of Cx32 as the underlying molecular mechanism, because a dominant negative effect theory is not applicable in these patients.     

Molecular analysis of the litaf/simple and prx genes in patients with demyelinating charcot‐marie‐tooth (CMT) disease

Mutations in the GJB1/Cx32 gene (Xq13.1) cause the most common X‐linked form of CMT (CMTX1) and are the most frequent cause of CMT disease after the CMT1A duplication. The disorder is characterized by a moderate‐to‐severe neuropathy in affected males and mild‐to‐no symptoms in carrier females. We report here a CMT1A‐negative family in which 4 females and 2 males were affected, exhibiting different disease severity. Molecular analysis of the GJB1/Cx32 gene uncovered a nonsense mutation (Arg22stop) in exon 2. The mutation, which had been previously described by others and observed by us in numerous other families, occurred in heterozygous form in the 4 females. However, while one of the two male patients was severely affected and shown to be hemizygous, as expected, the other was mildly affected and found to carry the mutation in heterozygous form. Genotyping at the SRY (Yp11.3) and DMD (Xp21) loci suggested the occurrence of the XXY genotype associated with Klinefelter syndrome. Microsatellite analysis indicated that the nondysjunctional error was of paternal origin, as it is usually observed in about half the cases. The patient had no children. At clinical examination, he exhibited a very mild neurologic phenotype and showed signs of hypogonadism (mild gynecomastia and small testes) as well as moderate cognitive impairment. Electrophysiologic, cytogenetic and endocrinologic investigations are in progress in order to define the unusual phenotype in this patient.     

A novel deletion mutation in GJB1 causes X-linked Charcot-Marie-Tooth disease in a Han Chinese family

X-linked Charcot-Marie-Tooth disease CMT (CMTX) is predominantly caused by mutations in the GJB1 gene that encode connexin32. We describe the clinical findings and the identification of a novel mutation in GJB1 in a large Han Chinese family with CMTX. Linkage to GJB1 was determined by genotyping five polymorphic markers flanking GJB1. Sequence alterations were determined by directly sequencing the coding region of the GJB1 gene. The affected members have variable clinical manifestations. Linkage analysis confirmed the cosegregation of the disease with the GJB1 locus. Sequencing of the GJB1 gene revealed a 1-basepair deletion (c.110delT) in the coding region. The frameshift begins at amino acid 37 and generates a premature stop codon at position 83. The shortened peptide is unlikely to be functional, as it lacks most of the functional domains. The CMTX in this family is caused by a novel loss of function mutation.     

腓骨肌萎缩症X1型1个家系的临床、电生理和Connexin32基因突变分析

目的观察腓骨肌萎缩症(CMT)X1型的临床、电生理特点和Connexin32(Cx32)基因突变情况.方法对1个无基因重复的临床可疑的CMTX1家系中的3例患者进行详尽的临床和神经电生理检查,并应用变性高效液相色谱结合混和样品池法和DNA序列测定对包括先证者在内的3名成员的Cx32基因进行突变检测.结果 该家系中的病人发生了Gly12Ser,50名正常人中未发现上述改变,提示该突变为致病性突变.家系中男性病人临床症状重于女性;电生理特点为脱髓鞘改变;同一病人的不同神经间存在异质性.结论 Gly12Ser突变可能导致原发性脱髓鞘性神经病,不伴有特殊的临床表现.     

Charcot‐Marie‐Tooth type X: unusual phenotype of a novel CX32 mutation

Background: X‐linked Charcot‐Marie‐Tooth disease (CMTX), caused by mutations in the gene encoding connexin32, is the second most common form of inherited demyelinating neuropathy, next to CMT 1A, and accounts for 10–20% of all hereditary demyelinating neuropathies. Aims of the study: To describe clinical and electrophysiological data of an Italian family carrying a novel mutation in the Cx32 gene. Patients and methods: Clinical, electrophysiological, and genetic findings of three patients carrying the Ser128Leu mutation in the intracellular domain of the Cx32 gene were reported. Brain MRI studies were also performed. Results: In our family the disease was characterized by a moderate‐to‐severe polyneuropathy affecting similarly males as well females. In the proband the phenotype was quite unusual in terms of late‐onset, rapidity of evolution and severity. Abnormal brain MRI in association with CNS symptoms were also observed. Both sons had also clinical evidence of CNS involvement. Conclusions: The Ser128Leu mutation in the Cx‐32 gene is a novel substitution, which has not been reported so far. This novel mutation could be added to the group of Cx‐32 mutations with CNS phenotypes. The identification of new CMTX causing mutations is a crucial step for carrier detection and pre‐symptomatic diagnosis.