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Multiple clinical trials employing recombinant adeno-associated viral (rAAV) vectors have been initiated for neuromuscular disorders, including Duchenne and limb-girdle muscular dystrophies, spinal muscular atrophy, and recently X-linked myotubular myopathy (XLMTM). Our previous work on a canine model of XLMTM showed that a single rAAV8-cMTM1 systemic infusion corrected structural abnormalities within the muscle and restored contractile function, with affected dogs surviving more than 4 years post injection. This remarkable therapeutic efficacy presents a unique opportunity to identify the downstream molecular drivers of XLMTM pathology and to what extent the whole muscle transcriptome is restored to normal after gene transfer. Herein, RNA-sequencing was used to examine the transcriptomes of the Biceps femorisand Vastus lateralisin a previously described canine cohort that showed dose-dependent clinical improvements after rAAV8-cMTM1 gene transfer. Our analysis confirmed several dysregulated genes previously observed in XLMTM mice but also identified transcripts linked to XLMTM pathology. We demonstrated XLMTM transcriptome remodeling and dose-dependent normalization of gene expression after gene transfer and created metrics to pinpoint potential biomarkers of disease progression and correction.

Myotonic dystrophy type 1 (DM1) is caused by a CTG repeat expansion located in the 3′ UTR of the DMPKgene. Expanded DMPKtranscripts aggregate into nuclear foci and alter the function of RNA-binding proteins, leading to defects in the alternative splicing of numerous pre-mRNAs. To date, there is no curative treatment for DM1. Here we investigated a gene-editing strategy using the CRISPR-Cas9 system from Staphylococcus aureus(Sa) to delete the CTG repeats in the human DMPKlocus. Co-expression of SaCas9 and selected pairs of single-guide RNAs (sgRNAs) in cultured DM1 patient-derived muscle line cells carrying 2,600 CTG repeats resulted in targeted DNA deletion, ribonucleoprotein foci disappearance, and correction of splicing abnormalities in various transcripts. Furthermore, a single intramuscular injection of recombinant AAV vectors expressing CRISPR-SaCas9 components in the tibialis anterior muscle of DMSXL (myotonic dystrophy mouse line carrying the human DMPKgene with >1,000 CTG repeats) mice decreased the number of pathological RNA foci in myonuclei. These results establish the proof of concept that genome editing of a large trinucleotide expansion is feasible in muscle and may represent a useful strategy to be further developed for the treatment of myotonic dystrophy.

X-linked myotubular myopathy (XLMTM) is a severe congenital disorder in male infants that leads to generalized skeletal muscle weakness and is frequently associated with fatal respiratory failure. XLMTM is caused by loss-of-function mutations in the MTM1gene, which encodes myotubularin, the founder member of a family of 15 homologous proteins in mammals. We recently demonstrated the therapeutic efficacy of intravenous delivery of rAAV vectors expressing MTM1 in animal models of myotubular myopathy. Here, we tested whether the closest homologues of MTM1, MTMR1, and MTMR2 (the latter being implicated in Charcot-Marie-Tooth neuropathy type 4B1) are functionally redundant and could represent a therapeutic target for XLMTM. Serotype 9 recombinant AAV vectors encoding either MTM1, MTMR1, or MTMR2 were injected into the tibialis anterior muscle of Mtm1-deficient knockout mice. Two weeks after vector delivery, a therapeutic effect was observed with Mtm1and Mtmr2, but not Mtmr1; with Mtm1being the most efficacious transgene. Furthermore, intravenous administration of a single dose of the rAAV9-Mtmr2vector in XLMTM mice improved the motor activity and muscle strength and prolonged survival throughout a 3-month study. These results indicate that strategies aiming at increasing MTMR2 expression levels in skeletal muscle may be beneficial in the treatment of myotubular myopathy.

La myopathie myotubulaire est une maladie pédiatrique fatale due à des mutations dans le gène codant la myotubularine (MTM1), une phosphoinositide 3-phosphatase. Elle se caractérise par une faiblesse musculaire très sévère à la naissance ainsi qu’une détresse respiratoire limitant l’espérance de vie à moins d’un an pour la plupart des patients. Le modèle murin déficient en MTM1 (Mtm1-KO) reproduit les principales caractéristiques de la pathologie humaine, dont une faiblesse musculaire conduisant à la mort des animaux autour de 8 semaines. Dans un récent travail, nous avons identifié pour la première fois des altérations de fonction des cellules musculaires de souris Mtm1-KO qui jouent un rôle critique dans la physiopathologie de la maladie. De plus, nous avons révélé le bénéfice d’un traitement pharmacologique. Plus précisément, nous avons démontré que les altérations de signalisation calcique associées à la maladie sont hétérogènes au niveau subcellulaire, et qu’elles affectent non seulement l’amplitude mais aussi les cinétiques d’activation du flux de calcium qui génère la contraction. Nous avons par ailleurs montré que l’inhibition pharmacologique de l’activité phosphoinositide 3-kinase corrige de manière très substantielle les défauts de signalisation calcique in vitroet prolonge l’espérance de vie des souris déficientes en MTM1. La perturbation du métabolisme des phosphoinositides joue donc un rôle critique dans la pathologie et nos résultats fournissent une preuve de concept de bénéfice thérapeutique d’une approche pharmacologique.

X-linked myotubular myopathy (XLMTM) results from MTM1gene mutations and myotubularin deficiency. Most XLMTM patients develop severe muscle weakness leading to respiratory failure and death, typically within 2 years of age. Our objective was to evaluate the efficacy and safety of systemic gene therapy in the p.N155K canine model of XLMTM by performing a dose escalation study. A recombinant adeno-associated virus serotype 8 (rAAV8) vector expressing canine myotubularin (cMTM1) under the muscle-specific desmin promoter (rAAV8-cMTM1) was administered by simple peripheral venous infusion in XLMTM dogs at 10 weeks of age, when signs of the disease are already present. A comprehensive analysis of survival, limb strength, gait, respiratory function, neurological assessment, histology, vector biodistribution, transgene expression, and immune response was performed over a 9-month study period. Results indicate that systemic gene therapy was well tolerated, prolonged lifespan, and corrected the skeletal musculature throughout the body in a dose-dependent manner, defining an efficacious dose in this large-animal model of the disease. These results support the development of gene therapy clinical trials for XLMTM.

X-linked myotubular myopathy is a congenital myopathy caused by deficiency of myotubularin. Patients often present with severe perinatal weakness, requiring mechanical ventilation to prevent death from respiratory failure. We recently reported that an activin receptor type IIB inhibitor produced hypertrophy of type 2b myofibers and modest increases of strength and life span in the severely myopathic Mtm1δ4 mouse model of X-linked myotubular myopathy. We have now performed a similar study in the less severely symptomatic Mtm1p.R69C mouse in hopes of finding greater treatment efficacy. Activin receptor type IIB inhibitor treatment of Mtm1p.R69C animals produced behavioral and histological evidence of hypertrophy in gastrocnemius muscles but not in quadriceps or triceps. The ability of the muscles to respond to activin receptor type IIB inhibitor treatment correlated with treatment-induced increases in satellite cell number and several muscle-specific abnormalities of hypertrophic signaling. Treatment-responsive Mtm1p.R69C gastrocnemius muscles displayed lower levels of phosphorylated ribosomal protein S6 and higher levels of phosphorylated eukaryotic elongation factor 2 kinase than were observed in Mtm1p.R69C quadriceps muscle or in muscles from wild-type littermates. Hypertrophy in the Mtm1p.R69C gastrocnemius muscle was associated with increased levels of phosphorylated ribosomal protein S6. Our findings indicate that muscle-, fiber type-, and mutation-specific factors affect the response to hypertrophic therapies that will be important to assess in future therapeutic trials.

Myotubular myopathy (MTM) is a severe congenital muscle disease characterized by profound weakness, early respiratory failure and premature lethality. MTM is defined by muscle biopsy findings that include centralized nuclei and disorganization of perinuclear organelles. No treatments currently exist for MTM. We hypothesized that aberrant neuromuscular junction (NMJ) transmission is an important and potentially treatable aspect of the disease pathogenesis. We tested this hypothesis in two murine models of MTM. In both models we uncovered evidence of a disorder of NMJ transmission: fatigable weakness, improved strength with neostigmine, and electrodecrement with repetitive nerve stimulation. Histopathological analysis revealed abnormalities in the organization, appearance and size of individual NMJs, abnormalities that correlated with changes in acetylcholine receptor gene expression and subcellular localization. We additionally determined the ability of pyridostigmine, an acetylcholinesterase inhibitor, to ameliorate aspects of the behavioral phenotype related to NMJ dysfunction. Pyridostigmine treatment resulted in significant improvement in fatigable weakness and treadmill endurance. In all, these results describe a newly identified pathological abnormality in MTM, and uncover a potential disease-modifying therapy for this devastating disorder.

X-linked myotubular myopathy is a severe congenital myopathy caused by deficiency of the lipid phosphatase, myotubularin. Recent studies of human tissue and animal models have discovered structural and physiological abnormalities in myotubularin-deficient muscle, but the impact of myotubularin deficiency on myogenic stem cells within muscles is unclear. In the present study, we evaluated the viability, proliferative capacity, and in vivoengraftment of myogenic cells obtained from severely symptomatic (Mtm1δ4) myotubularin-deficient mice. Mtm1δ4 muscle contains fewer myogenic cells than wild-type (WT) littermates, and the number of myogenic cells decreases with age. The behavior of Mtm1δ4 myoblasts is also abnormal, because they engraft poorly into C57BL/6/Rag1null/mdx5cv mice and display decreased proliferation and increased apoptosis compared with WT myoblasts. Evaluation of Mtm1δ4 animals at 21 and 42 days of life detected fewer satellite cells in Mtm1δ4 muscle compared with WT littermates, and the decrease in satellite cells correlated with progression of disease. In addition, analysis of WT and Mtm1δ4 regeneration after injury detected similar abnormalities of satellite cell function, with fewer satellite cells, fewer dividing cells, and increased apoptotic cells in Mtm1δ4 muscle. These studies demonstrate specific abnormalities in myogenic cell number and behavior that may relate to the progression of disease in myotubularin deficiency, and may also be used to develop in vitroassays by which novel treatment strategies can be assessed.

X-linked myotubular myopathy (XLMTM) is a congenital disorder caused by deficiency of the lipid phosphatase, myotubularin. Patients with XLMTM often have severe perinatal weakness that requires mechanical ventilation to prevent death from respiratory failure. Muscle biopsy specimens from patients with XLMTM exhibit small myofibers with central nuclei and central aggregations of organelles in many cells. It was postulated that therapeutically increasing muscle fiber size would cause symptomatic improvement in myotubularin deficiency. Recent studies have elucidated an important role for the activin-receptor type IIB (ActRIIB) in regulation of muscle growth and have demonstrated that ActRIIB inhibition results in significant muscle hypertrophy. To evaluate whether promoting muscle hypertrophy can attenuate symptoms resulting from myotubularin deficiency, the effect of ActRIIB-mFC treatment was determined in myotubularin-deficient (Mtm1δ4) mice. Compared with wild-type mice, untreated Mtm1δ4 mice have decreased body weight, skeletal muscle hypotrophy, and reduced survival. Treatment of Mtm1δ4 mice with ActRIIB-mFC produced a 17% extension of lifespan, with transient increases in weight, forelimb grip strength, and myofiber size. Pathologic analysis of Mtm1δ4mice during treatment revealed that ActRIIB-mFC produced marked hypertrophy restricted to type 2b myofibers, which suggests that oxidative fibers in Mtm1δ4animals are incapable of a hypertrophic response in this setting. These results support ActRIIB-mFC as an effective treatment for the weakness observed in myotubularin deficiency.

We have studied the ability of GDNF and neurturin to promote the in vitrosurvival of populations of embryonic chicken parasympathetic, sympathetic, and sensory neurons. We show that these neurons are more responsive to one or other of these factors at particular stages of development. Whereas the parasympathetic neurons are more sensitive to neurturin at late embryonic stages, sympathetic neurons are more sensitive to neurturin at early stages. In contrast, sensory neurons of the nodose ganglion are more sensitive to GDNF throughout embryonic development. Using competitive RT/PCR, we measured the levels of mRNAs encoding GDNF and neurturin receptors in purified neurons. All neurons expressed Ret mRNA, which encodes the common receptor tyrosine kinase for GDNF and neurturin. Neurons that were more sensitive to GDNF expressed higher levels of GFRα-1 mRNA than GFRα-2 mRNA and neurons that were more sensitive to neurturin expressed higher levels of GFRα-2 mRNA than GFRα-1 mRNA. These results show that populations of PNS neurons differ markedly in their responsiveness to GDNF and neurturin at certain stages of the development and suggest that these differences are governed in part by the relative levels of expression of members of the GFRα family of GPI-linked receptors.

The expression of BDNF mRNA by a proportion of embryonic dorsal root ganglion neurons has led to the proposal that BDNF acts by an autocrine loop on these neurons. To clarify the role of BDNF expression in developing sensory neurons, we measured the level of BDNF mRNA in purified populations of cranial sensory neurons that depend on either NGF or BDNF for survival. When neuronal death is taking place, the highest levels of BDNF mRNA were detected in NGF-dependent cutaneous sensory neurons. BDNF mRNA was expressed at lower levels in BDNF-dependent cutaneous sensory neurons and was undetectable in BDNF-dependent proprioceptive neurons. In coculture, NGF-dependent neurons promoted the survival of BDNF-dependent neurons by the production and release of BDNF. Depolarizing levels of KCl increased the expression of BDNF mRNA in cultured sensory neurons and this effect was partially inhibited by calcium channel antagonists. Our results suggest that during the phase of naturally occurring neuronal death, BDNF acts by a paracrine mechanism in sensory neurons and that BDNF expression is regulated by neural activity.

Recent work has shown that the survival of the nerve growth factor (NGF)-dependent trigeminal ganglion neurons of the mouse embryo is promoted by brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) during the early stages of target field innervation (Buchman and Davies, (1993) Development, 118, 989-1001). The present study was undertaken to ascertain if responsiveness to multiple neurotrophins is a universal feature of the early stages of neuronal development or is restricted to only certain kinds of neurons. To address this issue, we took advantage of the accessibility, from an early developmental stage, of several populations of cranial sensory neurons in the chicken embryo that depend for survival on just one or two known neurotrophins during the phase of naturally occurring cell death. During the mid-embryonic period (E10 to E12) when the number of sensory neurons is declining due to naturally occurring neuronal death, the neurons of the jugular ganglion and the dorsomedial part of the trigeminal ganglion (DMTG) were supported by NGF, the neurons of the ventrolateral part of the trigeminal ganglion (VLTG) were supported by BDNF and the nodose ganglion contained a major subset of neurons supported by BDNF and a minor subset supported by NT-3. Earlier in development (E6), the survival of DMTG and jugular neurons was additionally promoted by BDNF and NT-3. In contrast, E6 VLTG neurons did not exhibit a survival response to either NGF or NT-3, and E6 nodose neurons did not exhibit a survival response to NGF.(ABSTRACT TRUNCATED AT 250 WORDS)

Recent work has shown that the survival of the nerve growth factor (NGF)-dependent trigeminal ganglion neurons of the mouse embryo is promoted by brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) during the early stages of target field innervation (Buchman and Davies, (1993) Development, 118, 989–1001). The present study was undertaken to ascertain if responsiveness to multiple neurotrophins is a universal feature of the early stages of neuronal development or is restricted to only certain kinds of neurons. To address this issue, we took advantage of the accessibility, from an early developmental stage, of several populations of cranial sensory neurons in the chicken embryo that depend for survival on just one or two known neurotrophins during the phase of naturally occurring cell death. During the mid-embryonic period (E10 to E12) when the number of sensory neurons is declining due to naturally occurring neuronal death, the neurons of the jugular ganglion and the dorsomedial part of the trigeminal ganglion (DMTG) were supported by NGF, the neurons of the ventrolateral part of the trigeminal ganglion (VLTG) were supported by BDNF and the nodose ganglion contained a major subset of neurons supported by BDNF and a minor subset supported by NT-3. Earlier in development (E6), the survival of DMTG and jugular neurons was additionally promoted by BDNF and NT-3. In contrast, E6 VLTG neurons did not exhibit a survival response to either NGF or NT-3, and E6 nodose neurons did not exhibit a survival response to NGF.(ABSTRACT TRUNCATED AT 250 WORDS)

GFRα-1, GFRα-2, and GFRα-3 constitute a family of structurally related, glycosyl-phosphatidylinosital-linked, cell surface proteins, two of which, GFRα-1 and GFRα-2, are components of the receptor complex for the neurotrophic factors GDNF and neurturin, respectively. By screening an embryonic chicken brain cDNA library with a GFRα-1 probe at low stringency, we isolated cDNAs encoding an additional member of the GFRα family, GFRα-4. The nucleotide sequence predicts a 431-amino-acid secreted protein that is more closely related to GFRα-1 and GFRα-2 than to GFRα-3. GFRα-4 mRNA is expressed in distinctive patterns in the brain and several other organs and tissues of the chicken embryo. Our findings extend the family of GFRα proteins and provide information about the tissues in which GFRα-4 may function during development.

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X-linked myotubular myopathy (XLMTM) is a devastating, rare, congenital myopathy caused by mutations in the MTM1 gene, resulting in a lack of or dysfunction of the enzyme myotubularin. This leads to severe perinatal weakness and distinctive muscle pathology. It was originally thought that XLMTM was related to developmental arrest in myotube maturation; however, the generation and characterization of several animal models have significantly improved our understanding of clinical and pathological aspects of this disorder. Myotubularin is now known to participate in numerous cellular processes including endosomal trafficking, excitation-contraction coupling, cytoskeletal organization, neuromuscular junction structure, autophagy, and satellite cell proliferation and survival. The available vertebrate models of XLMTM, which vary in severity from complete absence to reduced functional levels of myotubularin, recapitulate features of the human disease to a variable extent. Understanding how pathological endpoints in animals with XLMTM translate to human patients will be essential to interpret preclinical treatment trials and translate therapies into human clinical studies. This review summarizes the published animal models of XLMTM, including those of zebrafish, mice, and dogs, with a focus on their pathological features as compared to those seen in human XLMTM patients.

Intravenous injection of an adeno-associated viral vector expressing the myotubularin (MTM1) gene improves survival and rescues skeletal muscle function in mice and dogs affected by myotubular myopathy.