Metabolic myopathies are myopathies that result from defects in biochemical metabolism that primarily affect muscle. They are generally genetic defects (inborn errors of metabolism) that interfere with the ability to create energy, causing a low ATP reservoir within the muscle cell.
Types
Metabolic myopathies are generally caused by an inherited genetic mutation, an inborn error of metabolism. (In livestock, an acquired environmental GSD is caused by intoxication with the alkaloid castanospermine.)Stegelmeier BL, Molyneux RJ, Elbein AD, James LF (May 1995). "The lesions of locoweed (Astragalus mollissimus), swainsonine, and castanospermine in rats". Veterinary Pathology. 32 (3): 289–98. PMID 7604496. S2CID 45016726. Metabolic myopathies cause the underproduction of adenosine triphosphate (ATP) within the muscle cell.
The genetic mutation typically has an autosomal recessive hereditary pattern making it fairly rare to inherit, and even more rarely it can be caused by a random de novo genetic mutation, or autosomal dominant, X-linked, or mitochondrial. Metabolic myopathies are categorized by the metabolic pathway to which the deficient enzyme or transport protein belongs. The main categories of metabolic myopathies are listed below: Muscle glycogen storage diseases (Muscle GSDs) and other inborn errors of carbohydrate metabolism that affect muscle—defect in sugar (carbohydrate) metabolism. The deficiency occurs in the cytosol of the muscle cell. Fatty acid metabolism disorder (fatty acid oxidation disorder, FAOD)—defect in fat (lipid) metabolism, anywhere along the pathway, starting from entering the muscle cell and ending at converting fatty acids into acetyl-CoA within the mitochondrion. The deficiency occurs in the cell membrane, cytosol, mitochondrial membrane, or within the mitochondrion of the muscle cell. Nucleotide metabolism disorder—defect in purine nucleotide cycle enzyme (such as AMP deaminase deficiency). Purine nucleotide metabolism is a part of protein catabolism, and the purine nucleotide cycle occurs within the cytosol of the muscle cell. Mitochondrial myopathy—defect in mitochondrial enzymes or transport proteins for oxidative phosphorylation (including citric acid cycle and electron transport chain), excluding those for fatty acid oxidation. Occurs in the mitochondrial membrane or within the mitochondrion of the muscle cell.
Symptoms and signs In the event more ATP is needed from the affected pathway, the lack of it becomes an issue and symptoms develop. People with a metabolic myopathy often experience symptoms such as: Exercise intolerance, Abnormal muscle fatigue (premature fatigue and/or inability to get into second wind), muscle pain (myalgia), cramping or muscle stiffness during and/or after exercise, Shortness of breath (dyspnea), or rapid breathing (tachypnea), or heavy breathing (hyperpnea), or both (exercise hyperventilation) Inappropriate rapid heart rate in response to exercise (tachycardia), Exaggerated cardiorespiratory (breath and heart rate combined) response to exercise (dyspnea/tachypnea/hyperpnea and tachycardia), Exercise-induced myogenic hyperuricemia (exercise-induced accelerated breakdown of purine nucleotides in muscle via adenylate kinase reaction and purine nucleotide cycle), Transient muscle contracture or pseudomyotonia (like a really bad cramp that can last for hours, which is myogenic and EMG silent), May have progressive muscle weakness, May have a pseudoathletic appearance (hypertrophy or pseudohypertrophy) especially of the calves, Reddish-brown urine (myoglobinuria) and considerable breakdown of muscle tissue (rhabdomyolysis).
The degree of symptoms varies greatly from person to person and is dependent on the severity of enzymatic or transport protein defect. In extreme cases it can lead to rhabdomyolysis. The symptoms experienced also depend on which metabolic pathway is impaired, as different metabolic pathways produce ATP at different time periods during activity and rest, as well as the type of activity (anaerobic or aerobic) and its intensity (level of ATP consumption).
A majority of patients with metabolic myopathies have dynamic rather than static findings, typically experiencing exercise intolerance, muscle pain, and cramps with exercise rather than fixed muscle weakness. However, a minority of metabolic myopathies have fixed muscular weakness rather than exercise intolerance, imitating an inflammatory myopathy or limb girdle muscular dystrophy. It is uncommon that both static and dynamic signs predominate.
Mechanism At the cellular level, metabolic myopathies lack some kind of enzyme or transport protein that prevents the chemical reactions necessary to create adenosine triphosphate (ATP). ATP is often referred to as the "molecular unit of currency" of intracellular energy transfer. The lack of ATP prevents the muscle cells from being able to function properly. Some people with a metabolic myopathy never develop symptoms due to the body's ability to produce enough ATP through alternative pathways (e.g. the majority of those with AMP-deaminase deficiency are asymptomatic).
H2O + ATP → H+ + ADP + Pi + energy → muscle contraction
ATP is needed for muscle contraction by two processes:
Firstly, ATP is needed for transport proteins to actively transport calcium ions into the sarcoplasmic reticulum (SR) of the muscle cell between muscle contractions. Afterwards, when a nerve signal is received, calcium channels in the SR open briefly and calcium rushes into the cytosol by selective diffusion (which does not use ATP) in what is called a "calcium spark." The diffusion of calcium ions into the cytosol causes the myosin strands of the myofibril to become exposed, and the myosin strands pull the actin microfilaments together. The muscle begins to contract. Secondly, ATP is needed to allow the myosin to release and pull again, so that the muscle can contract further in what is known as the sliding filament model.
ATP is consumed at a high rate by contracting muscles. The need for ATP in muscle cells is illustrated by the phenomenon of Rigor mortis, which is the muscle rigidity that occurs in dead bodies for a short time after death. In these muscles, all the ATP has been used up and in the absence of further ATP being generated, the calcium transport proteins stop pumping calcium ions into the sarcoplasmic reticulum and the calcium ions gradually leak out. This causes the myosin proteins to grab the actin and pull once, but without further supply of ATP, cannot release and pull again. The muscles therefore remain rigid in the position at death until the binding of myosin to actin begins to break down and they become loose again. Diagnosis The symptoms of a metabolic myopathy can be easily confused with the symptoms of another disease. As genetic sequencing research progresses, a non-invasive neuromuscular panel DNA test can help make a diagnosis. Whole genome sequencing is required in more complex cases. If the DNA test is inconclusive (negative or VUS), then a muscle biopsy is necessary for an accurate diagnosis. In mitochondrial myopathies involving a single mtDNA deletion, DNA would have to be tested from affected muscle tissue rather than saliva or blood as unaffected tissues would show normal or near normal levels of mtDNA.
A blood test for creatine kinase (CK) can be done under normal circumstances to test for signs of tissue breakdown, or with an added cardio portion that can indicate if muscle breakdown is occurring. In metabolic myopathies, baseline CK is either normal or elevated. An electromyography (EMG) test is sometimes taken in order to rule out other disorders if the cause of fatigue is unknown. In metabolic myopathies, the EMG is either normal or myopathic, but spontaneous activity is usually absent.
An exercise stress test can be used to determine an inappropriate rapid heart rate (sinus tachycardia) response to exercise, which is seen in GSD-V, other glycogenoses, and mitochondrial myopathies. A 12 Minutes Walk Test (12MWT) can also be used to determine "second wind" which is also seen in McArdle disease (GSD-V) and phosphoglucomutase deficiency (PGM1-CDG/CDG1T/GSD-XIV).
A cardiopulmonary exercise test can measure both heart rate and breathing, to evaluate the oxygen cost (∆V'O2/∆Work-Rate) during incremental exercise. In both glycogenoses and mitochondrial myopathies, patients displayed an increased oxygen cost during exercise compared to control subjects; and therefore, can perform less work for a given V̇O2 consumption during submaximal daily life exercises.
In fatty acid oxidation disorders (FAOD), while at rest, some exhibit cardiac arrhythmia (commonly various forms of tachycardia, but more rarely, conduction disorders or acute bradycardia); while others have a normal heart rhythm.
Some GSDs and a mitochondrial myopathy are known to have a pseudoathletic appearance. McArdle disease (GSD-V) and late-onset Pompe disease (GSD-II) are known to have hypertrophy, particularly of the calf muscles. Cori/Forbes disease (GSD-III) is known to have hypertrophy of the sternocleidomastoid, trapezius, quadriceps, and thigh muscles. Muscular dystrophy, limb-girdle, type 1H (which as of 2017 was excluded from LGMD for showing signs on muscle biopsy as being a mitochondrial myopathy, but not yet assigned new nomenclature) is also known to have hypertrophy of the calf muscles. Hereditary myopathy with lactic acidosis (HML), another mitochondrial myopathy, also has hypertrophy of the calf muscles in some.
Blood test may show a disturbance in pH, with lactic acidosis (low pH) in mitochondrial myopathies either at rest or exercise-induced. Glycogen storage diseases may show transient exercise-induced alkalosis (high pH), hyperammonemia, and myogenic hyperuricemia. During a non-ischemic forearm exercise test, in GSDs the plasma lactate typically fails to rise (and may fall below resting levels); except for a few GSDs such as phosphoglucomutase deficiency (GSD-XIV), deficiency of functioning myophosphorylase-a (autosomal dominant PYGM), phosphorylase-b kinase deficiency (GSD-IXd), and Pompe disease (GSD-II) where lactate production is normal. In myoadenylate deaminase deficiency (AMPD1 deficiency), there is no rise in ammonia. Some fatty acid oxidation disorders show lactic acidosis, hypoketotic hypoglycaemia and hyperammonemia, while others are asymptomatic.
Differentiating between different types of metabolic myopathies can be difficult due to the similar symptoms of each type such as myoglobinuria and exercise intolerance. It has to be determined whether the patient has fixed (static) or exercise-induced (dynamic) manifestations; and if exercise-related, what kind of exercise, before extensive exercise-related lab testing is done to determine the underlying cause.
Adequate knowledge is required of the body's bioenergetic systems, including: which circumstances constitute anaerobic exercise (blood flow restricted by contracted muscles, insufficient oxygen and blood borne fuels, particularly isometric exercise, as well as sudden increased intensity) versus aerobic exercise (blood flow unrestricted); anaerobic metabolism (phosphagen system and anaerobic glycolysis — ATP produced without oxygen, regardless of adequate blood flow or not, quickly produces ATP which is useful in high-intensity activity and the beginning of any activity) versus aerobic metabolism (oxidative phosphorylation — ATP produced with oxygen, adequate blood flow required, slow to produce ATP but produces for longer and high yield); the different sources of ATP (phosphagen system, carbohydrate metabolism, lipid metabolism [including ketosis], protein metabolism [including the purine nucleotide cycle], oxidative phosphorylation); how long does each source take to start producing ATP; how long does each source continue to produce ATP; how long does each source take to replenish;