This article is about a type of spinal muscular atrophy linked to a genetic defect in the AR gene. For a list of other conditions with similar names, see Spinal muscular atrophies.
| Spinal and bulbar muscular atrophy |
| Classification and external resources |
| ICD-10 |
G12.1 |
| ICD-9 |
335.1 |
| OMIM |
313200 |
| DiseasesDB |
7144 |
| eMedicine |
article/1172604 |
| MeSH |
D055534 |
Spinal and bulbar muscular atrophy (SBMA), also known as spinobulbar muscular atrophy, bulbo-spinal atrophy, X-linked bulbospinal neuropathy (XBSN), X-linked spinal muscular atrophy type 1 (SMAX1), and Kennedy's disease (KD) — is a debilitating neurodegenerative disorder resulting in muscle cramps and progressive weakness due to degeneration of motor neurons in the brain stem and spinal cord.
The condition is associated with mutation of the androgen receptor (AR) gene[1][2][3] and is inherited in an X-linked recessive manner. As with many genetic disorders, no cure is known, although research continues.
Because of its endocrine manifestations related to the impairment of the AR gene, SBMA can be viewed as a variation of the disorders of the androgen insensitivity syndrome (AIS). It is also related to other neurodegenerative diseases caused by similar mutations, such as Huntington's disease and the spinocerebellar ataxias.
Contents
- 1 Genetics
- 2 Pathophysiology
- 3 Signs and symptoms
- 3.1 Neuromuscular
- 3.2 Homozygous females
- 4 History
- 5 See also
- 6 References
Genetics
SBMA is inherited in an X-linked recessive pattern.
The androgen receptor gene that is mutated in SBMA is located on the X chromosome, and the effects of the mutation may be androgen-dependent, thus only males are fully affected. Females are rarely affected; female carriers tend to have a relatively mild expression of the disease if they show symptoms at all.
Please note that the diagrams will be different if 1) the father is affected AND the mother is unaffected OR 2) if the father is affected and the mother is a carrier.
Pathophysiology
As reported in 1991, SBMA is caused by expansion of a CAG repeat in the first exon of the androgen receptor gene (trinucleotide repeats).[4] The CAG repeat encodes a polyglutamine tract in the androgen receptor protein. The greater the expansion of the CAG repeat, the earlier the disease onset and more severe the disease manifestations. The repeat expansion likely causes a toxic gain of function in the receptor protein, since loss of receptor function in androgen insensitivity syndrome does not cause motor neuron degeneration. Spinal and bulbar muscular atrophy may share mechanistic features with other disorders that are caused by polyglutamine expansion, such as Huntington's disease. There is currently no treatment or cure for SBMA.
It is a lower motor neuron disease.[5]
Signs and symptoms
SBMA patients have muscle cramps and progressive weakness due to degeneration of motor neurons in the brain stem and spinal cord.
Ages of onset and severity of manifestations in affected males vary from adolescence to old age, but most commonly develop in middle adult life. The latest onset was described in a male of 84 years of age. KD does not usually compromise longevity. The syndrome has neuromuscular and endocrine manifestations.
Neuromuscular
Early signs often include weakness of tongue and mouth muscles, fasciculations, and gradually increasing weakness of limb muscles with muscle wasting. In some cases, premature muscle fatigue begins in adolescence. Neuromuscular management is supportive, and the disease progresses very slowly but can eventually lead to extreme disability.
Neurological:
- Bulbar signs: The bulbar muscles are those supplied by the motor nerves from the brain stem, which control swallowing, breathing, speech, and other functions of the throat. Bulbar signs are problems with these muscles.
- Lower motor neuron signs: The lower motor neurons are those in the brainstem and spinal cord that directly supply the muscles. Loss of lower motor neurons leads to weakness and wasting of the muscle.
- Primary sensory neuropathy: Loss of sensation and numbness, usually not noticeable.
- Intention tremor: Hand tremor with volitional effort.
- Babinski (plantar) response: When the bottom of the foot is scraped, the toes bend down. An abnormal response would be an upward movement of the toes indicating a problem with higher level (upper) motor neurons.
- Decreased or absent deep tendon reflexes: When a doctor taps the knee, for example, with a tendon hammer, there is less than normal movement or none at all.
Muscular:
- Fasciculations: Twitching of muscles when at rest.
- Cramps: Large muscle spasms.
- Muscular atrophy: Loss of muscle bulk that occurs when the lower motor neurons do not stimulate the muscle adequately.
Endocrine
- Gynecomastia: breast enlargement.
- Impotence
- Erectile dysfunction
- Reduced fertility
- Low sperm count
- Testicular atrophy: Testicles become smaller and less functional.
Miscellaneous Characteristics:
- Late onset: Patients usually develop symptoms in the late 30's or afterwards.
- Symmetry of clinical signs: Muscles are usually affected symmetrically.
Homozygous females
Homozygous females, both of whose X chromosomes have a mutation leading to CAG expansion of the AR gene, have been reported to show only mild symptoms of muscle cramps and twitching. No endocrinopathy has been described.
History
This disorder was first described by Dr. William R. Kennedy in 1968.[6] In 1991 it was recognized that the AR gene is involved in the disease process. The disease is probably more common than originally thought. A study in Scandinavia suggested a prevalence of 1.3/8,500 making KD the most common form of motor neuron disease in the specific area studied[citation needed]; nobody had been diagnosed before 1995. It has been suggested that some men with SBMA may be misdiagnosed to have amyotrophic lateral sclerosis (ALS).
See also
- Spinal muscular atrophies
References
- ^ Krivickas, L. S. (2003). "Amyotrophic lateral sclerosis and other motor neuron diseases". Physical Medicine and Rehabilitation Clinics of North America 14 (2): 327–345. doi:10.1016/S1047-9651(02)00119-5. PMID 12795519. edit
- ^ Fischbeck, K. H.; Lieberman, A.; Bailey, C. K.; Abel, A.; Merry, D. E. (1999). "Androgen receptor mutation in Kennedy'sdisease". Philosophical Transactions of the Royal Society B: Biological Sciences 354 (1386): 1075. doi:10.1098/rstb.1999.0461. edit
- ^ Chen CJ, Fischbeck KH (2006). "Ch. 13: Clinical aspects and the genetic and molecular biology of Kennedy's disease". In Tetsuo Ashizawa; Wells, Robert V. Genetic Instabilities and Neurological Diseases (2nd ed.). Boston: Academic Press. pp. 211–222. ISBN 0-12-369462-0.
- ^ Spada, A. R. L.; Wilson, E. M.; Lubahn, D. B.; Harding, A. E.; Fischbeck, K. H. (1991). "Androgen receptor gene mutations in X-linked spinal and bulbar muscular atrophy". Nature 352 (6330): 77–79. doi:10.1038/352077a0. PMID 2062380. edit
- ^ Merry, D. E. (2005). "Animal Models of Kennedy Disease". NeuroRX 2 (3): 471–479. doi:10.1602/neurorx.2.3.471. PMC 1144490. PMID 16389310. edit
- ^ Kennedy, W. R.; Alter, M.; Sung, J. H. (1968). "Progressive proximal spinal and bulbar muscular atrophy of late onset. A sex-linked recessive trait". Neurology 18 (7): 671–680. doi:10.1212/WNL.18.7.671. PMID 4233749. edit
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Sex linkage: X-linked disorders
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X-linked recessive
|
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| Immune |
- Chronic granulomatous disease (CYBB)
- Wiskott–Aldrich syndrome
- X-linked severe combined immunodeficiency
- X-linked agammaglobulinemia
- Hyper-IgM syndrome type 1
- IPEX
- X-linked lymphoproliferative disease
- Properdin deficiency
|
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| Hematologic |
- Haemophilia A
- Haemophilia B
- X-linked sideroblastic anemia
|
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| Endocrine |
- Androgen insensitivity syndrome/Kennedy disease
- KAL1 Kallmann syndrome
- X-linked adrenal hypoplasia congenita
|
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| Metabolic |
- Amino acid: Ornithine transcarbamylase deficiency
- Oculocerebrorenal syndrome
- Dyslipidemia: Adrenoleukodystrophy
- Carbohydrate metabolism: Glucose-6-phosphate dehydrogenase deficiency
- Pyruvate dehydrogenase deficiency
- Danon disease/glycogen storage disease Type IIb
- Lipid storage disorder: Fabry's disease
- Mucopolysaccharidosis: Hunter syndrome
- Purine-pyrimidine metabolism: Lesch–Nyhan syndrome
- Mineral: Menkes disease/Occipital horn syndrome
|
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| Nervous system |
- X-linked mental retardation: Coffin–Lowry syndrome
- MASA syndrome
- X-linked alpha thalassemia mental retardation syndrome
- Siderius X-linked mental retardation syndrome
- Eye disorders: Color blindness (red and green, but not blue)
- Ocular albinism (1)
- Norrie disease
- Choroideremia
- Other: Charcot–Marie–Tooth disease (CMTX2-3)
- Pelizaeus–Merzbacher disease
- SMAX2
|
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| Skin and related tissue |
- Dyskeratosis congenita
- Hypohidrotic ectodermal dysplasia (EDA)
- X-linked ichthyosis
- X-linked endothelial corneal dystrophy
|
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| Neuromuscular |
- Becker's muscular dystrophy/Duchenne
- Centronuclear myopathy (MTM1)
- Conradi–Hünermann syndrome
- Emery–Dreifuss muscular dystrophy 1
|
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| Urologic |
- Alport syndrome
- Dent's disease
- X-linked nephrogenic diabetes insipidus
|
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| Bone/tooth |
- AMELX Amelogenesis imperfecta
|
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| No primary system |
- Barth syndrome
- McLeod syndrome
- Smith–Fineman–Myers syndrome
- Simpson–Golabi–Behmel syndrome
- Mohr–Tranebjærg syndrome
- Nasodigitoacoustic syndrome
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X-linked dominant
|
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- X-linked hypophosphatemia
- Focal dermal hypoplasia
- Fragile X syndrome
- Aicardi syndrome
- Incontinentia pigmenti
- Rett syndrome
- CHILD syndrome
- Lujan–Fryns syndrome
- Orofaciodigital syndrome 1
- Craniofrontonasal dysplasia
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Non-Mendelian inheritance: anticipation
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| Trinucleotide |
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Polyglutamine (PolyQ), CAG
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- Dentatorubral-pallidoluysian atrophy
- Huntington's disease
- Kennedy disease
- Spinocerebellar ataxia 1, 2, 3, 6, 7, 17 (Machado-Joseph disease)
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Non-polyglutamine
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- CGG (Fragile X syndrome)
- GAA (Friedreich's ataxia)
- CTG (Myotonic dystrophy type 1)
- CTG (Spinocerebellar ataxia 8)
- CAG (Spinocerebellar ataxia 12)
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| Tetranucleotide |
- CCTG (Myotonic dystrophy type 2)
|
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| Pentanucleotide |
- ATTCT (Spinocerebellar ataxia 10)
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Genetic disorder, protein biosynthesis: Transcription factor/coregulator deficiencies
|
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| (1) Basic domains |
| 1.2 |
- Feingold syndrome
- Saethre–Chotzen syndrome
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| 1.3 |
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(2) Zinc finger
DNA-binding domains |
| 2.1 |
- (Intracellular receptor): Thyroid hormone resistance
- Androgen insensitivity syndrome
- Kennedy's disease
- PHA1AD pseudohypoaldosteronism
- Estrogen insensitivity syndrome
- X-linked adrenal hypoplasia congenita
- MODY 1
- Familial partial lipodystrophy 3
- SF1 XY gonadal dysgenesis
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| 2.2 |
- Barakat syndrome
- Tricho–rhino–phalangeal syndrome
|
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| 2.3 |
- Greig cephalopolysyndactyly syndrome/Pallister–Hall syndrome
- Denys–Drash syndrome
- Duane-radial ray syndrome
- MODY 7
- MRX 89
- Townes–Brocks syndrome
- Acrocallosal syndrome
- Myotonic dystrophy 2
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| 2.5 |
- Autoimmune polyendocrine syndrome type 1
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| (3) Helix-turn-helix domains |
| 3.1 |
- ARX
- Ohtahara syndrome
- Lissencephaly X2
- MNX1
- HOXD13
- PDX1
- LMX1B
- MSX1
- Tooth and nail syndrome
- OFC5
- PITX2
- POU4F3
- POU3F4
- ZEB1
- Posterior polymorphous corneal dystrophy
- Fuchs' dystrophy 3
- ZEB2
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| 3.2 |
- PAX2
- PAX3
- PAX4
- PAX6
- Gillespie syndrome
- Coloboma of optic nerve
- PAX8
- Congenital hypothyroidism 2
- PAX9
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| 3.3 |
- FOXC1
- Axenfeld syndrome 3
- Iridogoniodysgenesis, dominant type
- FOXC2
- Lymphedema–distichiasis syndrome
- FOXE1
- Bamforth–Lazarus syndrome
- FOXE3
- Anterior segment mesenchymal dysgenesis
- FOXF1
- FOXI1
- Enlarged vestibular aqueduct
- FOXL2
- Premature ovarian failure 3
- FOXP3
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| 3.5 |
- IRF6
- Van der Woude syndrome
- Popliteal pterygium syndrome
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(4) β-Scaffold factors
with minor groove contacts |
| 4.2 |
- Hyperimmunoglobulin E syndrome
|
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| 4.3 |
- Holt–Oram syndrome
- Li–Fraumeni syndrome
- Ulnar–mammary syndrome
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| 4.7 |
- Campomelic dysplasia
- MODY 3
- MODY 5
- SF1
- SRY XY gonadal dysgenesis
- Premature ovarian failure 7
- SOX10
- Waardenburg syndrome 4c
- Yemenite deaf-blind hypopigmentation syndrome
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| 4.11 |
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| (0) Other transcription factors |
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| Ungrouped |
- TCF4
- ZFP57
- TP63
- Rapp–Hodgkin syndrome/Hay–Wells syndrome/Ectrodactyly–ectodermal dysplasia–cleft syndrome 3/Limb–mammary syndrome/OFC8
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| Transcription coregulators |
| Coactivator: |
- CREBBP
- Rubinstein–Taybi syndrome
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| Corepressor: |
- HR (Atrichia with papular lesions)
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See also transcription factors and intracellular receptors
- B structural
- perx
- skel
- cili
- mito
- nucl
- sclr
- DNA/RNA/protein synthesis
- membrane
- transduction
- trfk
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