Innervation of dystrophic muscle after muscle stem cell therapy

Introduction: Duchenne muscular dystrophy (DMD) is caused by loss of the structural protein, dystrophin, resulting in muscle fragility. Muscle stem cell (MuSC) transplantation is a potential therapy for DMD. It is unknown whether donor‐derived muscle fibers are structurally innervated. Methods: Green fluorescent protein (GFP)–expressing MuSCs were transplanted into the tibials anterior of adult dystrophic mdx/mTR mice. Three weeks later the neuromuscular junction was labeled by immunohistochemistry. Results: The percent overlap between pre‐ and postsynaptic immunolabeling was greater in donor‐derived GFP⁺ myofibers, and fewer GFP⁺ myofibers were identified as denervated compared with control GFP^– fibers (P = 0.001 and 0.03). GFP⁺ fibers also demonstrated acetylcholine receptor fragmentation and expanded endplate area, indicators of muscle reinnervation (P = 0.008 and 0.033). Conclusion: It is unclear whether GFP⁺ fibers are a result of de novo synthesis or fusion with damaged endogenous fibers. Either way, donor‐derived fibers demonstrate clear histological innervation. Muscle Nerve 54 : 763–768, 2016     

Clinical and genetic associations of autoantibodies to 3‐hydroxy‐3‐methyl‐glutaryl‐coenzyme a reductase in patients with immune‐mediated myositis and necrotizing myopathy

Introduction: Inhibition of 3‐hydroxy‐3‐methyl‐glutaryl‐coenzyme A reductase (HMGCR) with statins may trigger idiopathic inflammatory myositis (IIM) or immune‐mediated necrotizing myopathy (IMNM). Anti‐HMGCR antibodies have been detected in patients with IIM/IMNM. We aimed to determine the associations of anti‐HMGCR in IIM/IMNM. Methods: Anti‐HMGCR antibodies were detected by ELISA in sera from patients with IIM/IMNM. Results: Anti‐HMGCR antibodies were detected in 19 of 207 patients with IIM/IMNM, and there was a trend toward an association with male gender (P = 0.079). Anti‐HMGCR antibodies were associated strongly with statin exposure (OR = 39, P = 0.0001) and HLA‐DRB1*11 (OR = 50, P < 0.0001). The highest risk for development of anti‐HMGCR antibodies was among HLA‐DR11 carriers exposed to statins. Univariate analysis showed a strong association of anti‐HMGCR antibodies with diabetes mellitus (P = 0.008), which was not confirmed by multiple regression. Among anti‐HMGCR⁺ patients there was a trend toward increased malignancy (P = 0.15). Conclusions: Anti‐HMGCR antibodies are seen in all subtypes of IIM and IMNM and are associated strongly with statin use and HLA‐DR11. Muscle Nerve 52 : 196–203, 2015     

Human leukocyte antigen class I in polymyositis: Leukocyte infiltrates,regeneration, and impulse block

In polymyositis (PM), T-cell mediated myocytotoxicity is directed against strongly human leukocyte antigen class I positive (HLA-I⁺) muscle fibers. Fiber regeneration probably is partly responsible for this HLA-I up-regulation. We have evaluated regeneration, denervation/impulse blockade, and focal leukocyte infiltrates as possible HLA-I inducing factors in PM. Distinctive patterns of HLA-I, nerve cell adhesion molecule (NCAM), and vimentin expression accompany denervation and regeneration. Regenerating fibers also have centralized nuclei. Using semiquantitative methods, we examined strongly HLA-I⁺ fibers in PM muscle biopsies for these markers. Sarcoplasmic HLA-I levels were related to the presence of leukocyte infiltrates and invasion of fibers. Strongly HLA-I⁺ fibers were frequently invaded, and regeneration-associated changes were usually observed at sites of fiber damage. Sarcoplasmic HLA-I levels were stable along intact fibers, also adjacent to leukocyte infiltrates. A majority of the strongly HLA-I⁺ fibers were nonregenerating (NCAM⁺ only). Though other mechanisms cannot be excluded, this suggests that impulse blockade or denervation may contribute to extra HLA-I up-regulation in these fibers. © 1997 John Wiley & Sons, Inc. Muscle Nerve 20: 1534–1540, 1997     

Contrasting echogenicity in flexor digitorum profundus–flexor carpi ulnaris: A diagnostic ultrasound pattern in sporadic inclusion body myositis

Introduction: In this study we aimed to clarify whether muscle ultrasound (US) of the forearm can be used to differentiate between patients with sporadic inclusion body myositis (s‐IBM) and those with s‐IBM–mimicking diseases. Methods: We compared the echo intensity (EI) of the flexor digitorum profundus (FDP) muscle and the flexor carpi ulnaris (FCU) muscles in patients with s‐IBM (n = 6), polymyositis/dermatomyositis (PM/DM; n = 6), and amyotrophic lateral sclerosis (ALS; n = 6). Results: We identified EI abnormalities in 100% of patients with s‐IBM, 33% of those with PM/DM, and 33% of those with ALS. An “FDP–FCU echogenicity contrast,” a US pattern involving a higher EI in the FDP than in the FCU, was observed in all patients with s‐IBM, but in none of those with PM/DM or ALS. Conclusions: FDP–FCU echogenicity contrast in muscle US is a sensitive diagnostic indicator of s‐IBM. Muscle Nerve 49 : 745–748, 2014     

Muscle phenotype in patients with myotonic dystrophy type 1

Introduction: The pathogenesis of muscle involvement in patients with myotonic dystrophy type 1 (DM1) is not well understood. In this study, we characterized the muscle phenotype in patients with confirmed DM1. Methods: In 38 patients, muscle strength was tested by hand‐held dynamometry. Myotonia was evaluated by a handgrip test and by analyzing the decrement of the compound muscle action potential. Muscle biopsies were assessed for morphological changes and Na⁺‐K⁺ pump content. Results: Muscle strength correlated with a decline in Na⁺‐K⁺ pump content (r = 0.60, P < 0.001) and with CTG expansion. CTG expansion did not correlate with severity of myotonia, proximal histopathological changes, or Na⁺‐K⁺ pump content. Histopathologically, we found few centrally placed nuclei (range 0.2–6.9%). Conclusions: The main findings of this study are that muscle weakness correlated inversely with CTG expansion and that central nuclei are not a prominent feature of proximal muscles in DM1. Muscle Nerve 47:409‐415, 2013     

Measurement of platelet‐derived microparticle levels using an enzyme‐linked immunosorbent assay in polymyositis and dermatomyositis patients

Platelet‐derived microparticle (PDMP) levels were measured using an enzyme‐linked immunosorbent assay (ELISA) to elucidate the role of platelet activation in patients with polymyositis or dermatomyositis (PM/DM). PDMP levels in active PM/DM patients (median 13.3 U/ml, interquartile range 9.9–20.7 U/ml, n = 16) and those in patients undergoing treatment (12.1 U/ml, 7.4–16.7 U/ml, n = 12) were significantly higher than in controls (6.5 U/ml, 5.0–8.4 U/ml, n = 26, vs. active, P = 0.0001; vs. treatment, P = 0.004). In a paired sampling study, PDMP decreased significantly after glucocorticoid treatment (P = 0.04). PDMP in the active PM/DM patients correlated significantly with serum C‐reactive protein levels (r_s = 0.67, P = 0.01). These results suggest that platelets may play an important role in the inflammatory process, and that PDMP level could be a useful marker of inflammatory activity in PM/DM patients. Muscle Nerve 39: 586–590, 2009     

Upregulation of chemokines and their receptors in duchenne muscular dystrophy: potential for attenuation of myofiber necrosis

Introduction: In Duchenne muscular dystrophy (DMD), the infiltration of skeletal muscle by immune cells aggravates disease, yet the precise mechanisms behind these inflammatory responses remain poorly understood. Chemotactic cytokines, or chemokines, are considered essential recruiters of inflammatory cells to the tissues. Methods: We assayed chemokine and chemokine receptor expression in DMD muscle biopsies (n = 9, average age 7 years) using immunohistochemistry, immunofluorescence, and in situ hybridization. Results: CXCL1, CXCL2, CXCL3, CXCL8, and CXCL11, absent from normal muscle fibers, were induced in DMD myofibers. CXCL11, CXCL12, and the ligand–receptor couple CCL2–CCR2 were upregulated on the blood vessel endothelium of DMD patients. CD68⁺ macrophages expressed high levels of CXCL8, CCL2, and CCL5. Conclusions: Our data suggest a possible beneficial role for CXCR1/2/4 ligands in managing muscle fiber damage control and tissue regeneration. Upregulation of endothelial chemokine receptors and CXCL8, CCL2, and CCL5 expression by cytotoxic macrophages may regulate myofiber necrosis. Muscle Nerve, 2012     

Expression of intercellular adhesion molecule‐1 by myofibers in mdx mice

Introduction: We investigated the extent to which intercellular adhesion molecule‐1 (ICAM‐1), a critical protein of the inflammatory response, is expressed in skeletal muscles of mdx mice (a murine model of Duchenne muscular dystrophy). Methods: Muscles were collected from control and mdx mice at 2‐24 weeks of age and analyzed for ICAM‐1 expression by means of Western blot and immunofluorescence. Results: Western blot revealed higher expression of ICAM‐1 in mdx compared with control muscles through 24 weeks of age. In contrast to control muscles, ICAM‐1 was expressed on the membrane of damaged, regenerating, and normal myofibers of mdx mice. CD11b+ myeloid cells also expressed ICAM‐1 in mdx muscles, and CD11b+ cells were closely associated with the membrane of myofibers expressing ICAM‐1. Conclusions: These findings support a paradigm in which ICAM‐1 and its localization to myofibers in muscles of mdx mice contributes to the dystrophic pathology. Muscle Nerve 52: 795–802, 2015     

Sarcolemmal excitability in the myotonic dystrophies

Introduction: Chloride conductance disturbances contribute to sarcolemmal dysfunction in myotonic dystrophy type 1 (DM1) and type 2 (DM2). Studies using muscle velocity recovery cycles (MVRCs) suggest Na⁺/K⁺‐adenosine triphosphatase activation becomes defective in advanced DM1. We used MVRCs to investigate muscle excitability in DM1 and DM2. Methods: MVRCs were measured for patients with mild (n = 8) and advanced (n = 11) DM1, DM2 (n = 4), and normal controls (n = 30). Results: Residual supernormality after multiple conditioning stimuli was increased in DM2 and advanced DM1. Advanced DM1 was distinguished by increases in muscle relative refractory period (MRRP) and reduced early supernormality as well as peak amplitude decrements for the first and last responses in train during repetitive stimulation. Discussion: Prolongation of the MRRP indicates that depolarization of the resting muscle membrane potential occurs in advanced DM1, with possible implications for future therapeutic approaches. Muscle Nerve 57 : 595–602, 2018     

Autoimmune Myopathies: Updates on Evaluation and Treatment

The major forms of autoimmune myopathies include dermatomyositis (DM), polymyositis (PM), myositis associated with antisynthetase syndrome (ASS), immune-mediated necrotizing myopathy (IMNM), and inclusion body myositis (IBM). While each of these conditions has unique clinical and histopathological features, they all share an immune-mediated component. These conditions can occur in isolation or can be associated with systemic malignancies or connective tissue disorders (overlap syndromes). As more has been learned about these conditions, it has become clear that traditional classification schemes do not adequately group patients according to shared clinical features and prognosis. Newer classifications are now utilizing myositis-specific autoantibodies which correlate with clinical and histopathological phenotypes and risk of malignancy, and help in offering prognostic information with regard to treatment response. Based on observational data and expert opinion, corticosteroids are considered first-line therapy for DM, PM, ASS, and IMNM, although intravenous immunoglobulin (IVIG) is increasingly being used as initial therapy in IMNM related to statin use. Second-line agents are often required, but further prospective investigation is required regarding the optimal choice and timing of these agents.     

Impaired autophagy correlates with golden retriever muscular dystrophy phenotype

Introduction: Duchenne muscular dystrophy (DMD) and golden retriever muscular dystrophy (GRMD) are X‐linked disorders caused by mutations in the DMD gene. Autophagy was recently identified as a secondary therapeutic target for DMD. We hypothesized that autophagy would be reduced in GRMD. Methods: Autophagic gene and protein expression was assessed in normal and GRMD skeletal muscles and correlated with phenotypic biomarkers. Results: Muscles were differentially affected. Autophagy gene levels were lower than normal in the GRMD cranial sartorius (CS) but similar in the vastus lateralis (VL). Protein markers of autophagic flux, LC3B‐II and p62, were higher in both GRMD muscles, in keeping with impaired autophagy. Protein levels correlated with a more severe phenotype. Autophagic structures were found in necrotic, fast‐twitch GRMD myofibers. Discussion: Our data suggest that autophagy is impaired in certain GRMD muscles. Differential GRMD CS involvement emphasizes that therapeutic modulation of autophagy could require specific muscle targeting. Muscle Nerve 58 : 418–426, 2018     

In vivo assessment of muscle membrane properties in myotonic dystrophy

Introduction: Myotonia in myotonic dystrophy types 1 (DM1) and 2 (DM2) is generally attributed to reduced chloride‐channel conductance. We used muscle velocity recovery cycles (MVRCs) to investigate muscle membrane properties in DM1 and DM2, using comparisons with myotonia congenita (MC). Methods: MVRCs and responses to repetitive stimulation were compared between patients with DM1 (n = 18), DM2 (n = 5), MC (n = 18), and normal controls (n = 20). Results: Both DM1 and DM2 showed enhanced late supernormality after multiple conditioning stimuli, indicating delayed repolarization as in MC. Contrary to MC, however, DM1 showed reduced early supernormality after multiple conditioning stimuli, and weak DM1 patients also showed abnormally slow latency recovery after repetitive stimulation. Conclusions: These findings support the presence of impaired chloride conductance in both DM1 and DM2. The early supernormality changes indicate that sodium currents were reduced in DM1, whereas the weakness‐associated slow recovery after repetitive stimulation may provide an indication of reduced Na⁺/K⁺‐ATPase activation. Muscle Nerve 54 : 249–257, 2016     

Electrical stimulation influences satellite cell differentiation after sciatic nerve crush injury in rats

Introduction: Electrical stimulation is often used to prevent muscle atrophy and preserve contractile function, but its effects on the satellite cell population after nerve injury are not well understood. In this study we aimed to determine whether satellite cell differentiation is affected by electrical stimulation after nerve crush. Methods: The sciatic nerves of Sprague‐Dawley (SD) rats were crushed. Half of the injured rats received daily electrical stimulation of the gastrocnemius muscle, and the others did not. Tests for detecting paired box protein 7 (Pax7), myogenic differentiation antigen (MyoD), embryonic myosin heavy chain (eMyHC), and force production were performed 2, 4, and 6 weeks after injury. Results: More Pax7⁺/MyoD⁺ nuclei in stimulated muscles were observed than in non‐stimulated muscles. eMyHC expression was elevated in stimulated muscles and correlated positively with enhanced force production. Conclusions: Increased satellite cell differentiation is correlated with preserved muscle function in response to electrical stimulation after nerve injury. Muscle Nerve 51: 400–411, 2015     

The effects of FK506 on refractory inflammatory myopathies

We performed an observational clinical study, the effects of tacrolimus (FK506) on the thymic output in patients with refractory inflammatory myopathies. Sixteen patients with polymyositis (PM) and 15 with dermatomyositis (DM) were treated orally with tacrolimus. Serum CK levels significantly decreased 2 to 4 months after tacrolimus therapy (p < 0.01), and MRC (Medical Research Council) scores were significantly improved 2 months after tacrolimus therapy (p < 0.01). T-cell receptor excision circle (TREC) content, a proxy for thymic export was not significantly different from that in age-matched controls, except for an increase in the TREC content within CD8+ single positive cells in patients with DM. TREC contents within double-positive cells and CD4+ single-positive cells were significantly decreased 4 M after tacrolimus therapy (p < 0.05) in PM/DM patients. Tacrolimus treatment significantly attenuated TREC content within cultured CD4+CD8- cells from PM/DMpatients (p < 0.05), but total cell counts were not significantly changed. These results indicate that tacrolimus therapy suppresses not only activated T-lymphocytes, but also some na?ve T-cell subsets in both PM and DM.     

Optineurin is potentially associated with TDP‐43 and involved in the pathogenesis of inclusion body myositis

S. Yamashita, E. Kimura, N. Tawara, H. Sakaguchi, T. Nakama, Y. Maeda, T. Hirano, M. Uchino and Y. Ando (2013) Neuropathology and Applied Neurobiology 39, 406–416 Optineurin is potentially associated with TDP‐43 and involved in the pathogenesis of inclusion body myositis Aims: Increasing evidences suggest a similarity in the pathophysiological mechanisms of neuronal cell death in amyotrophic lateral sclerosis (ALS) and myofibre degeneration in sporadic inclusion body myositis (sIBM). The aim of this study is to elucidate the involvement of ALS‐causing proteins in the pathophysiological mechanisms in sIBM. Methods: Skeletal muscle biopsy specimens of five patients with sIBM, two with oculopharyngeal muscular dystrophy (OPMD), three with polymyositis (PM), three with dermatomyositis (DM), three with neurogenic muscular atrophy, and three healthy control subjects were examined. We analysed the expression and localization of familial ALS‐causing proteins, including transactive response DNA binding protein‐43 (TDP‐43), fused in sarcoma/translocated in liposarcoma (FUS/TLS), Cu/Zn superoxide dismutase (SOD1) and optineurin (OPTN) by immunohistochemistry. Results: TDP‐43, OPTN and, to a lesser extent, FUS/TLS were more frequently accumulated in the cytoplasm in patients with sIBM and OPMD than in patients with PM, DM, neurogenic muscular atrophy, or healthy control subjects. SOD1 was accumulated in a small percentage of myofibres in patients with sIBM and OPMD, and to a very small extent in patients with PM and DM. Confocal microscopy imaging showed that TDP‐43 proteins more often colocalized with OPTN than with FUS/TLS, p62 and phosphorylated Tau. Conclusions: These findings suggest that OPTN in cooperation with TDP‐43 might be involved in the pathophysiological mechanisms of skeletal muscular degeneration in myopathy with rimmed vacuoles. Further investigation into these mechanisms is therefore warranted.     

Muscle endurance deficits in myositis patients despite normal manual muscle testing scores

Introduction: It is unclear whether quantitating muscle endurance adds nonredundant information useful for the care of patients with muscular disease. Methods: Records were retrospectively reviewed for all Johns Hopkins Myositis Center patients with a muscle endurance assessment (n = 128, 226 patient-visits). Muscle endurance and strength were quantitated with the Myositis Functional Index-2 (FI2) and manual muscle testing (MMT), respectively. Results: Composite FI2 muscle endurance scores were comparable in inclusion body myositis (n = 58), dermatomyositis (n = 31), and polymyositis (n = 39). Overall, muscle endurance correlated with and evolved similarly to strength, inversely to serum creatine kinase. However, in patients with normal or near-normal strength (mean MMT > 9.75/10), muscle endurance was typically abnormal and highly variable (mean FI2, 5.6/10; interquartile range, 3.3-7.8/10). Discussion: Muscle endurance testing may identify muscle impairment inadequately described by MMT, particularly in patients with high MMT scores. Muscle Nerve 59 :70–75, 2019     

Human CD8 TCR-αβ and TCR-γδ cells modulate autologous autoreactive neuroantigen-specific CD4 T-cells by different mechanisms

To investigate the regulatory interactions among autologous T-cells during the course of multiple sclerosis (MS), proteolipid protein peptide-specific CD4⁺ T-cell clones (TCCs) were irradiated and used as immunogens to stimulate purified populations of autologous CD8⁺ TCR-αβ⁺ and TCR-γδ⁺ T-cells isolated from the peripheral blood of MS patients, patients with other non-inflammatory neurological diseases, and healthy blood donors. The resulting blasts were expanded in the presence of hIL-2 and then cloned by limiting dilution. Two different groups of CD8⁺ TCCs were revealed. A first group of CD8⁺ TCCs recognized autologous CD4⁺ T-cells based in their TCRVβ structures (anti-idiotypic responsiveness). A second group of CD8⁺ TCCs recognized Ag activated autologous CD4⁺ TCCs irrespective of their Ag specificity or TCRVβ expression (anti-ergotypic responsiveness). Both groups showed MHC class I restricted cytotoxicity against CD4⁺ T-cells and were able to secrete IFN-γ, TNFα/β and TGF-β. TCR-γδ⁺ TCCs isolated in response to stimulation with autologous peptide-specific CD4⁺ TCCs showed only anti-ergotypic cytotoxicity, which was not inhibited by anti-MHC class Ia monoclonal antibodies. Moreover, they were able to secrete IFN-γ and TNFα/β, but not TGF-β. These data demonstrate that regulatory mechanisms among human autologous T-cells can be mediated by cytolytic interactions or by the release of specific cytokines. Furthermore, they provide evidence that CD8⁺ TCR-αβ⁺ and TCR-γδ⁺ cells differ in their patterns of recognition and in their abilities to modulate the immune response mediated by autologous autoreactive CD4⁺ T-cells.     

L-Selectin Expression Affects T-Cell Circulation Following Isoproterenol Infusion in Humans

β-Adrenergic receptor agonists have been shown to affect leukocyte migration. This study examined the expression of cellular adhesion molecules on lymphocyte, monocyte, and granulocyte distribution following an infusion of isoproterenol (20 and 40 ng/kg/min for 15 min each) in 12 healthy subjects. Leukocyte populations and adhesion molecule expression were determined via flow cytometry. Isoproterenol led to an expected lymphocytosis and leukocytosis. L-selectin expression varied across leukocytes and influenced cell trafficking in response to isoproterenol. Approximately 60% of CD8⁺T-cells expressed L-selectin (CD8⁺CD62L⁺) and these cells showed no appreciable response to isoproterenol. In contrast, CD8⁺CD62L⁻cells showed a robust increase in number and distribution of approximately 100% over baseline (p’s < .001). Across CD4⁺T-helpers, L-selectin was expressed on approximately 86% of cells. CD4⁺CD62L⁺cells decreased in number and distribution (p’s < .001) with isoproterenol, while CD4⁺CD62L⁻cells showed a modest increase (p’s < .05). In contrast to lymphocytes, nearly all monocytes and granulocytes expressed L-selectin; these cells increased and decreased respectively in response to isoproterenol (p’s < .05). CD11a (the β₂-integrin LFA-1) was expressed on >95% of all leukocytes and these data were thus similar to the overall leukocytosis data. CD54 (ICAM-1) was expressed on approximately 60% of mixed lymphocytes and was unchanged in response to isoproterenol. The findings indicate that L-selectin expression influences T-cell trafficking in response to β-adrenergic stimulation and help further illuminate catecholamine-mediated sympathetic and immune interactions.