Secondarily reduced cytochrome c oxidase activity in various neuromuscular disorders

Decreased cytochrome c oxidase (CCO) activity was found in various neuromuscular diseases, including infantile spinal muscular atrophy (SMA) and Fukuyama type congenital muscular dystrophy (FCMD), that was thought to result from a secondarily induced mitochondrial defect. To determine whether or not the enzyme activities in the mitochondrial electron transport system can be secondarily changed, we measured the enzyme activities in denervated rat muscles. The CCO activity decreased progressively to 38-47% of the control value in 3 weeks after denervation, the NADH-cytochrome c reductase and succinate-cytochrome c reductase activities remaining unchanged, suggesting that the CCO activity may be easily reduced secondarily in various disease conditions.     

Infantile cytochrome c oxidase deficiency with neonatal death

A newborn male presented with severe respiratory insufficiency, generalized muscle weakness, and lactic acidemia. Immediately after admission, he was placed on a respirator because of respiratory arrest. He deteriorated rapidly and died 75 hours after birth. There was notable variation in fiber size and an increased number of type 2C fibers in the quadriceps femoris muscle obtained at autopsy; however, no ragged-red fibers were observed with modified Gomori trichrome staining. Markedly decreased cytochrome c oxidase activity was demonstrated in skeletal muscle by biochemical and histochemical studies, while cardiac muscle demonstrated normal cytochrome c oxidase activity. Mitochondrial myopathy should be considered in the differential diagnosis of patients with neonatal respiratory distress syndrome.     

Mitochondrial encephalomyopathy and partial cytochrome c oxidase deficiency

A 52-year-old man had slowly progressive weakness and wasting of limb-muscles, sensorineural hearing loss, and complex partial seizures. CT showed cerebral atrophy, but he was not demented. Muscle biopsy showed ragged-red fibers and decreased histochemical stain for cytochrome c oxidase. Biochemical studies showed decreased cytochrome c oxidase activity in crude muscle extracts and in isolated mitochondria (44 and 30% of normal), while other mitochondrial enzymes were normal. A comparable decrease of immunologically reactive enzyme protein was shown by immunotitration with antibodies against human heart cytochrome c oxidase. Partial defects of cytochrome c oxidase may cause adult-onset, slowly progressive mitochondrial encephalomyopathies.     

A morphometric study of muscle mitochondria in cytochrome c oxidase deficiency

Quantitative analysis of mitochondrial size and its percentage of total fibre volume in different muscle fibre types was performed on biceps brachii muscles of controls aged from 9 months to 10 years, and patients aged from 8 months to 14 years, with cytochrome c oxidase (CCO) deficiency confirmed by both histochemical and biochemical analyses. The disease was classified into 2 subgroups: one not containing ragged-red fibres (RRF) (group I), and one containing RRF (group II). Relationship between type 1 and 2 fibres in mitochondrial size and percentages of total fibre volume showed significant differences in the controls and group I. A comparison of the controls and group I did not show significant differences in mitochondrial size, but abnormally enlarged mitochondria were occasionally observed in the latter. In group I, statistical differences were observed in mitochondrial percentage of total fibre volume, though these differences remained in the control range, suggesting the presence of mild morphological changes in mitochondria on electron microscopy. In group II, mitochondrial size and its percentage of total fibre volume were markedly increased in both type 1 and 2 fibres, with no statistical differences observed between the 2 fibre types.     

Myopathy and fatal cardiopathy due to cytochrome c oxidase deficiency

A 3-day-old girl had a syndrome of lethargy and lactic acidosis. Pregnancy and delivery had been normal; there was no consanguinity or family history of neuromuscular disease. At age 4 1/2 months, she had generalized weakness, hypotonia, areflexia, and macroglossia. She developed cyanosis and respiratory failure, and marked cardiomegaly was noted. She died at age 8 1/2 months of cardiac arrest. Results from a muscle biopsy specimen obtained at age 4 1/2 months showed ragged-red fibers and increased glycogen and lipid droplets. With the cytochrome c oxidase reaction, only 5% of the fibers stained positively in the biopsy specimen. Cytochrome c oxidase activity was 7.3% of normal in muscle mitochondria and 12.2% of normal in heart mitochondria. Reduced-minus-oxidized cytochrome spectra showed lack of the cytochrome aa3 peak. Immunotitration using antibodies against purified human heart cytochrome c oxidase showed normal amount of cross-reacting material in both heart and muscle. The genetic error could have involved a cytochrome c oxidase isozyme common to heart and muscle.     

Progressive cytochrome c oxidase deficiency in a case of Leigh's encephalomyelopathy

We report the morphological, biochemical, immunological, and genetic findings in a patient with the clinical characteristics of Leigh's disease due to multisystemic cytochrome c oxidase (CCO) deficiency. Muscle biopsy at 2 years and 5 months of age showed markedly decreased CCO and cytochrome a + a3, moderately decreased NADH-cytochrome c reductase to 46.3%, and generalized loss of immunologically detectable CCO subunits, but other respiratory chain enzyme proteins were normal. All the tissues examined at autopsy showed decreased activity of all respiratory chain enzymes except complex II. The decrease in cytochromes b and a + a3 were in harmony with decreased enzyme activities in complex III and IV (CCO), respectively. All immunologically detectable subunits of CCO in immunoprecipitation were uniformly decreased in the cardiac and skeletal muscles, but subunits 1 and 4 were selectively decreased in other organs except liver. No large deletion could be detected in the cardiac muscle mtDNA after digestion with restriction enzymes. These results suggest that the respiratory chain enzymes are variable in their activity and the amount of enzyme proteins decreases as the disease progresses.     

Defects in muscle fiber growth in fatal infantile cytochrome c oxidase deficiency

In addition to numerous ragged-red fibers in the muscle from a female infant with fetal infantile cytochrome c oxidase deficiency, the muscle fibers were small in caliber with electron microscopic characteristics of immaturity; the satellite cells were significantly increased in number to 31.3% as compared with those in controls, 8.4 +/- 1.6% (p less than 0.001). In the culture system, the biopsied muscle showed markedly reduced growth despite the presence of numerous satellite cells which are known to act as myoblasts in muscle regeneration, and formed fewer numbers of myotubes containing poorly organized myofibrils and mitochondria with no cytochrome c oxidase activity. A defect in myogenesis and a paucity in repair process in severe form may account for the progressive course and a fatal outcome.     

MELAS-like episodes in an adult case with cytochrome c oxidase deficiency]

A 30-year-old man was hospitalized with dysarthria and weakness of his right arm and leg. Three months previously, he had noticed numbness and weakness of his right shoulder, which spread to involve his left leg but which improved after 8 months. On admission, neurological examination revealed limb kinetic apraxia and constructive apraxia of the right hand, motor aphasia, dysarthria, and spastic quadriplegia. Sensory examination revealed hyperalgesia and dysesthesia in the right arm and left leg. Deep tendon reflexes were hyperactive in all four extremities. And he had bilateral Babinski signs. Laboratory examination revealed pH 7.38, PCO2 46.1 Torr, PO2 93.4 Torr, BE 1.7, and blood lactate, 9.0 mg/dl (normal 5-20 mg/dl). Cerebrospinal fluid lactate level was 20.0 mg/dl. pyruvate 1.34 mg/dl. and protein 83 mg/dl. Blood lactate and pyruvate values were markedly elevated after aerobic exercise. T2WI brain MRI showed scattered high signal lesions in the left precentral and postcentral gyrus, right paracentral lobes, both superior frontal gyri, and right superior temporal gyrus. Right biceps brachi biopsy showed almost complete cytochrome c oxidase (COX) deficiency. There were no ragged-red fibers. There was marked decrease of COX activity: 2.7 nmol/min/mg-mitochondrial protein (normal range: 33.0 +/- 16.1, n = 7) in the biopsied muscle. Open brain biopsy (after permission from the patient and his family) revealed gliosis and perivascular infiltration of lymphocytes and macrophages without vascular proliferation. There was no mitochondrial DNA mutations, deletion or duplication, including tRNA-Leu 3243, 8993, 3271, 9176, 3291, and tRNA-Lys 8344, 8356, and 8363. From these findings, a diagnosis of COX deficiency presenting as MELAS-like episodes was done. His mother also showed abnormality on aerobic exercise test, but she had no episode of stroke or neurological dysfunction. Six months later, his aphasia and apraxia of the right hand had resolved, and at discharge he was able to ambulate with a cane. Ten months later, he returned to his work. There has been no recurrence of neurologic symptoms over the next 3 years and 10 months. This patient appears to represent a rare case of adult onset COX deficiency presenting as MELAS-like episodes.     

A partial deficiency of cytochrome c oxidase in chronic progressive external ophthalmoplegia

A partial deficiency of cytochrome oxidase has been found in 7 patients with chronic progressive external ophthalmoplegia and proximal myopathy or craniosomatic abnormalities. Muscle biopsies from all these patients showed morphological mitochondrial abnormalities (“ragged red” fibres) and cytochemical assay of cytochrome oxidase showed that these fibres contained no demonstrable enzyme activity. The incidence of cytochrome oxidase-negative fibres was greater than that of “ragged-red” fibres suggesting that the enzyme defect preceded the development of morphological mitochondrial changes. Biochemical analysis of skeletal muscle mitochondrial fractions from 3 patients revealed in 1 case a significantly lower concentration of cytochrome aa₃ and a decreased ratio of cytochrome oxidase/succinate-cytochrome c reductase. Fasting blood metabolites were elevated in 2 patients. We suggest that partial cytochrome oxidase deficiency is the underlying defect in mitochondrial myopathy associated with the oculocraniosomatic syndromes.     

Benign reversible muscle cytochrome c oxidase deficiency: a second case

A 6-week-old boy had generalized weakness, requiring assisted ventilation, and lactic acidosis. At 6 months, the lactic acidosis resolved, and the patient started to improve; assisted ventilation was discontinued at 15 months. Muscle biopsies at 4 and 11 months showed accumulation of mitochondria, lipid, and glycogen; cytochrome c oxidase (COX) activity was 11% of the lowest control in the first biopsy and 57% in the second. Immunocytochemistry and immunotitration showed presence of immunologically reactive enzyme protein in both biopsies. This case confirms a previous report of benign infantile myopathy due to reversible COX deficiency. The severe fibrosis in the second biopsy may explain the slower rate of clinical recovery in this child.     

Mitochondrial encephalomyopathies and cytochrome c oxidase deficiency: muscle culture study

Summary The populations of cytochrome c oxidase (CCO)-positive and-negative mitochondria were analyzed in the elongated cells containing occasional multiple nuclei (myotubes) in primary muscle cultures derived from patients with various forms of mitochondrial encephalomyopathies with CCO deficiency. Even in control muscle cultures, CCO-positive (79.7%) and -negative (20.3%) mitochondria were distributed randomly, showing intracellular mosaicism. All mitochondria in all muscle cultures from two patients with clinical characteristics of Leigh's disease exhibited faint to negative CCO activity. In these patients no enzyme activity could be detected in any tissue including intrafusal fibers and fibroblasts in muscle biopsies. In patients with the fatal infantile and the encephalomyopathic forms of CCO deficiency, and myoclonic epilepsy with ragged-red fibers, two different types of myotubes containing mostly CCO-positive mitochondria and only negative mitochondria, respectively, representing intercellular mosaicism, were demonstrated. The intercellular mosaicism in biopsied and cultured muscles in the case of CCO deficiency supports the contention that both CCO-positive and -negative mitochondria coexist in the early myogenic cell and later randomly segregated during cell division (mitotic segregation), forming two different cells.Support in part by Grants-in-Aid for Scientific Research (No. 0267032), Scientific Research on Priority Areas (No. 62617523) and Developmental Scientific Research (No. 62870041) from the Ministry of Education, Science and Culture of Japan     

Remarkable improvement in adult Leigh syndrome with partial cytochrome c oxidase deficiency

Leigh syndrome (LS) is a heterogeneous disorder, usually due to a defect in oxidative metabolism. Typically, signs and symptoms commence in infancy or childhood, although rare cases of adult onset have been described. Progressive deterioration is the norm. The authors describe a 22-year-old woman with partial cytochrome c oxidase deficiency who developed fulminant LS following an acute febrile illness and who subsequently showed dramatic clinical and neuroradiologic improvement.     

Endocrine involvement in mitochondrial encephalomyopathy with partial cytochrome c oxidase deficiency.

A 19-year-old man born with thyroprivic hypothyroidism, due to congenital development defect, manifested hypogonadism, stunted growth, chronic progressive external ophthalmoplegia (CPEO), diffuse muscle weakness and wasting, right bundle branch block, cerebral atrophy. Muscle biopsy showed mitochondrial abnormalities. Biochemical investigations on muscle disclosed partial (50%) cytochrome c oxidase deficiency, 58% decrease of cytochrome aa3 and 41% decrease of cytochrome b. Enzyme-linked immunosorbent assay showed decrease of the immunologically active enzyme protein.     

Benign infantile mitochondrial myopathy due to reversible cytochrome c oxidase deficiency

A 2-week-old boy had profound generalized weakness, hypotonia, hyporeflexia, macroglossia, and severe lactic acidosis. The infant improved spontaneously: he held his head at 4 1/2 months, rolled over at 7 months, and walked by 16 months. At 33 months of age, he had mild proximal weakness. Macroglossia disappeared by age 4 months. Blood lactic acid declined steadily and was normal by 14 months of age. Histochemical and ultrastructural studies of muscle biopsy specimens obtained at 1 and 7 months of age showed excessive mitochondria, lipid, and glycogen; a third biopsy at age 36 months showed only atrophy of scattered fibers. Cytochrome c oxidase stain was positive in fewer than 5% of fibers in the first biopsy, in approximately 60% of fibers in the second biopsy, and in all fibers in the third biopsy. Biochemical analysis showed an isolated defect of cytochrome c oxidase activity, which was only 8% of the lowest control level in the first biopsy; the activity increased to 47% in the second biopsy and was higher than normal in the third. In contrast to that in the fatal infantile form of cytochrome c oxidase deficiency, the enzyme defect in this condition is reversible. The biochemical basis for this difference remains to be explained.     

Enzyme activity measured in single muscle fibers in partial cytochrome c oxidase deficiency

Single-fiber analyses using a kinetic microphotometric method were performed on three patients with chronic progressive external ophthalmoplegia and proximal myopathy accompanied by a partial deficiency of cytochrome c oxidase. Two patients had subsarcolemmal accumulation of mitochondria (ragged-red fibers). Qualitative histochemical demonstration of cytochrome c oxidase showed a mosaic of fibers without detectable cytochrome c oxidase activity. Quantitative single fiber measurements in the patients' biopsies showed that the majority of the muscle fibers had decreased cytochrome c oxidase activity without selective involvement of a specific fiber type. Succinate dehydrogenase was measured and the ratio of the activities (succinate dehydrogenase/cytochrome c oxidase) was calculated. Normal muscle showed a ratio of about 2, whereas diseased muscle showed values between 10 and 20, due to a decrease in cytochrome c oxidase activity. Ragged-red fibers showed very low or undetectable cytochrome c oxidase activity.     

Benign mitochondrial myopathy with deficiency of NADH-CoQ reductase and cytochrome c oxidase

Since birth a female child had been weak and hypotonic. At three months of age, head control was lacking; sucking and crying were poor. Four months later, there were more spontaneous movements and the girl was able to push herself up in prone position. Further motor improvement was noted at the age of 15 months. A 25-year-old brother of the patient's mother was very floppy during early childhood and has still some difficulties to swallow. Laboratory work-up showed elevated blood lactate and pyruvate levels, a mild hyperalaninemia and hyperalaninuria and an increased urinary excretion of dicarboxylic acids. Light and electron microscopy of a muscle biopsy disclosed a mitochondria-lipid-glycogen myopathy. Biochemical studies on a second muscle specimen revealed a combined deficiency of NADH-CoQ reductase and cytochrome c oxidase with a low carnitine level. There exists a considerable clinical and biochemical heterogeneity among the myopathies due to disturbances in the mitochondrial respiratory chain.