Muscular dystrophy (MD) is a group of inherited muscle diseases that cause wasting and weakness of the muscles. MND (motor neurone disease), MS (multiple sclerosis), SMA (spinal muscular atrophy), or any other neurological acronym with an M in it. No. It’s long been clear that these disorders are heterogeneous, varying in age of onset, severity, pattern of muscle involvement and inheritance. In the past, useful classifications have been produced but these were always to some extent arbitrary and therefore controversial. The field was rife with nosological debate. Yes. A breakthrough came in 1987 when the causative gene for the most common severe form of MD, Duchenne muscular dystrophy (DMD — the field is rich in eponyms, too) was found. Since then, the genes affected in many MDs have been discovered, enabling classification and diagnosis to be put on a much more secure footing. Some traditional disease categories have split as a result (recessive limb girdle muscular dystrophy — LGMD — now has eight subtypes), whereas others have merged. The flood of genes and gene products has provided much opportunity for new names including the protein that is missing in Fukuyama dystrophy (another eponym), memorably called Fukutin. No. These changes to the classification allow physicians to offer more accurate prognosis and antenatal diagnosis. Better still, they give biological insight and may lead to therapy. No. For several diseases there are only linked loci. Especially interesting is fascioscapulohumeral dystrophy (mercifully, known as FSHD). FSHD is associated with specific deletions of chromosome 4q35 but no genes have been found in the region. Perhaps the deletion changes the structure of a neighbouring chromosomal region and alters transcription there (a ‘position effect’). Indeed, alterations in expression of several muscle-specific messenger RNAs have been found recently in FSHD. Not completely. Take DMD, for example. Dystrophin, the protein product of the mutated gene, normally sits at the muscle cell membrane but is lost in DMD. Several binding partners of dystrophin have been identified. The amino-terminal of dystrophin interacts with F-actin, part of the cellular cytoskeleton. The other end of dystrophin at the cell membrane binds a group of glycoproteins collectively known as the dystrophin-associated protein complex (DAPC). Among these are four sarcoglycans and dystoglycan, which binds via its extracellular portion to laminin-α2, a component of the extracellular matrix. Dystrophin thus links the internal structure of the muscle cell with the external matrix. Cells deficient in dystrophin are particularly prone to membrane damage from physical stresses, so a natural hypothesis is that dystrophin is an important structural component supporting the membrane. Fitting well with this, it turned out that mutations in the sarcoglycans and laminin-α2 all cause forms of MD. All looked good for the structural hypothesis, which attracted a catchphrase: ‘Dystrophin is a rubber band’. Yes. Recent findings have put the hypothesis under strain and stretched it to breaking point. Indeed, it may not bounce back. Well, it's not that straightforward. Dystrophin also binds α-dystrobrevin and, like several other components of the DAPC, α-dystrobrevin is lost from the membrane in DMD. Now, α-dystrobrevin knockout mice have been made. In these mice, dystrophin and the other elements on the putative intracellular–extracellular link are all intact, yet the mice still have muscular dystrophy. MD is a favourite of gene therapists. Preliminary studies using an adeno-associated virus to replace γ-sarcoglycan in patients with LGMD 2C have just started. One (non gene therapy) strategy for DMD is to upregulate utrophin (an autosomal homologue of dystrophin). Transgenic mice, deficient in dystrophin but overexpressing utrophin in muscle are spared MD. Bredt DS: Knocking signalling out of the dystrophin complex. Nat Cell Biol 1999, 1:E89-91. Brown SC, Lucy JA (Eds): Dystrophin: Gene, Protein and Cell Biology. Cambridge, UK: Cambridge University Press; 1997. Grady RM, Grange RW, Lau KS, Maimone MM, Nichol MC, Stull JT, Sanes JR: Role for α-dystrobrevin in the pathogenesis of dystrophin-dependent muscular dystrophies.Nat Cell Biol 1999, 1:215-220. Tinsley J, Deconinck N, Fisher R, Kahn D, Phelps S, Gillis JM, Davies K: Expression of full-length utrophin prevents muscular dystrophy in mdx mice. Nat Med 1998, 4:1441-1444. Tulper R, Perini G, Pellegrino MA, Green MR: Profound misregulation of muscle-specific gene expression in Fascioscapulohumeral dystrophy.Proc Nat Acad Sci USA 1999, 96:12650-12654.
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