本文選題：Leigh綜合征 + mtDNA�。� 參考：《山西醫(yī)科大學》2017年碩士論文

【摘要】：線粒體腦肌病(mitochondrial encephalomyopathy)是由于線粒體DNA(mitochondrial DNA,mt DNA)或核DNA(nucleus DNA,n DNA)缺陷導致線粒體結構和功能障礙、ATP合成不足所致的遺傳代謝性疾病,即為原發(fā)性線粒體疾病。目前明確的綜合征包括線粒體腦肌病伴高乳酸血癥和卒中樣發(fā)作(mitochondrial encephalomyopathy with lactic acidemia and stroke-like episodes,MELAS)、KSS綜合征(Kearns-Sayre syndrome,KSS)、慢性進行性眼外肌癱瘓(chronic progressive external ophthalmoplegia,CPEO)、Leigh綜合征(Leigh syndrome,LS)等多種綜合征。線粒體疾病的診斷需要結合其臨床表現(xiàn)、家族史、實驗室檢查、影像學資料、肌肉組織化學染色、線粒體呼吸鏈酶活性測定、mt DNA及n DNA的檢測等信息。每一種方法對于線粒體的功能評估都有著一定的局限性,需要綜合多方面的信息進行系統(tǒng)的分析。Leigh綜合征(Leigh syndrome,LS)也稱亞急性壞死性腦脊髓病,是與線粒體氧化磷酸化(OXPHOS)缺陷相關的進行性加重的神經(jīng)退行性疾病。主要受累人群是嬰幼兒和學齡前兒童,臨床癥狀主要是運動遲緩、智力低下、進行性認知功能減退、運動障礙、肌張力減退、共濟失調、腦干功能異常等。分為早發(fā)型LS和晚發(fā)型LS,暫時還不能從年齡上明確的將其分開。本文通過分析我院經(jīng)治的四例線粒體腦肌病患者的臨床資料,行骨骼肌活檢術及線粒體全基因檢測,明確全基因檢測在該病診斷中的價值。通過匯總分析已發(fā)表的Leigh綜合征(LS)病例,總結LS臨床癥狀和呼吸鏈酶復合物基因突變的發(fā)生率、發(fā)病年齡與基因突變類型之間的相關性。第一部分線粒體腦肌病四例:臨床、病理與基因分析目的:分析四例臨床疑診為線粒體病患者的臨床資料,行骨骼肌活檢術及線粒體全基因檢測,明確全基因檢測在該病診斷中的價值。方法:四例臨床表現(xiàn)疑似線粒體病的患者行肌肉活檢術及冰凍酶組織化學染色。對四例患者留取3ml外周血行線粒體全基因測序,應用Sanger測序、二代測序、MLPA、CNV等方法對mt DNA和n DNA進行檢測。結果:1.四例患者累及骨骼肌均表現(xiàn)為不同程度的四肢肌肉無力及運動不耐受,癥狀呈波動性且進行性加重;神經(jīng)系統(tǒng)損害表現(xiàn)為智力低下、癲癇等;其他系統(tǒng)表現(xiàn)如腎衰竭、代謝性酸中毒、視力下降、神經(jīng)性耳聾。CK值正常或輕度增高,多在1000U/L以下。兩例患者乳酸運動試驗陽性,其它兩例患者血氣中乳酸值增高。2.兩例患者頭顱MRS提示受損部位可見倒置的乳酸峰。3.肌肉活檢發(fā)現(xiàn)三例患者MGT染色上存在破碎紅纖維(RRFs),百分比為10%--80%,COX染色提示酶活性部分缺失。一例患者肌肉活檢未發(fā)現(xiàn)特異性RRF,但結合臨床表現(xiàn)、影像學檢查及基因檢測確診為線粒體腦病。4.線粒體全基因組測定發(fā)現(xiàn)一例患者為線粒體細胞色素B基因大片段缺失變異,兩例患者是線粒體核基因點突變,一例患者未發(fā)現(xiàn)明確致病性突變。結論:1.線粒體腦肌病的基因型、臨床表型具有高度異質性。2.臨床表現(xiàn)、影像學檢查、肌肉活檢、基因檢測是線粒體腦肌病診斷重要依據(jù)。第二部分385例Leigh綜合征患者臨床表現(xiàn)、基因突變分析目的:通過文獻資料回顧性分析評估Leigh綜合征(Leigh syndrome,LS)的臨床表現(xiàn),總結LS臨床癥狀及呼吸鏈酶復合物基因突變的發(fā)生率、發(fā)病年齡與基因突變類型之間的相關性。方法:采用R2.15.3軟件進行Meta分析。首先對每個臨床癥狀的發(fā)生率進行l(wèi)ogit轉換,然后以樣本量為權重計算合并率,最后得到合并的“發(fā)生率”及其95%CI。通過Homogeneity test(Q檢驗)進行異質性檢驗(檢驗水準為α=0.1),再結合I2定量判斷異質性的大小。若P0.10且I250%,提示研究結果之間存在異質性,采用隨機效應模型進行Meta分析;反之采用固定效應模型進行Meta分析。發(fā)表偏倚采用Eggers’test檢驗。最后通過排除最低質量的文獻后重新計算合并率來進行敏感性分析。Meta分析的檢驗水準為α=0.05。用Mann-Whitney秩和檢驗和Kruskal-Wallis秩和檢驗進行不同基因突變間發(fā)病年齡差異性分析。用多個率之間雙重比較的Pearson卡方檢驗進行常見臨床癥狀之間發(fā)生率的差異性分析,取P0.05有統(tǒng)計學差異。結果:共納入5篇文獻匯總了385例Leigh綜合征。臨床癥狀合并率的Meta分析結果為乳酸值增高62%、發(fā)育遲緩60%、肌張力減退47%、癲癇33%、眼肌受損與呼吸功能受損28%、肌肉無力27%、喂養(yǎng)困難26%、共濟失調20%。不同臨床癥狀之間發(fā)生率有統(tǒng)計學意義,乳酸值增高可能是最早期表現(xiàn),應注意早發(fā)現(xiàn)早診斷。對LS患者進行全基因測序,mt DNA與n DNA兩種基因發(fā)病年齡差異有統(tǒng)計學意義,mt DNA基因突變較n DNA年齡大。n DNA基因突變位點發(fā)病年齡有統(tǒng)計學意義,PDHA1基因發(fā)病年齡較晚,SLC19A3基因發(fā)病年齡最早。呼吸鏈酶復合物基因突變發(fā)生率Meta分析結果提示復合物I型34%、復合物IV 20%、復合物I+IV 15%、復合物V 9%。結論:LS臨床表現(xiàn)多種多樣,乳酸值增高可能是最早期表現(xiàn)。發(fā)病年齡與基因突變類型有關,呼吸鏈酶復合物基因突變是LS最常見原因,常見為復合物Ⅰ基因突變。
[Abstract]:Mitochondrial encephalomyopathy (mitochondrial encephalomyopathy) is due to mitochondrial DNA (mitochondrial DNA, MT DNA) or nuclear DNA (nucleus DNA, n DNA) defects resulting in mitochondrial structure and dysfunction, the genetic metabolic disease caused by deficiency of synthesis, that is, primary myelopathy. The present clear syndrome includes mitochondrial encephalomyopathy Hyperlactoemia and stroke like seizures (mitochondrial encephalomyopathy with lactic acidemia and stroke-like episodes, MELAS), KSS syndrome (Kearns-Sayre syndrome), chronic progressive extraocular paralysis, etc. The diagnosis of body disease needs to be combined with its clinical manifestations, family history, laboratory examination, imaging data, muscle histochemical staining, mitochondrial respiratory chain enzyme activity determination, MT DNA and N DNA detection. Each method has certain limitations for the evaluation of mitochondrial function, which requires a comprehensive and multiple information system. The analysis of.Leigh syndrome (Leigh syndrome, LS), also known as subacute necrotizing encephalomyelitis, is a progressive neurodegenerative disease associated with mitochondrial oxidative phosphorylation (OXPHOS) defects. The main affected population is infants and preschool children, and the main clinical symptoms are slow movement, mental retardation, progressive cognitive impairment, and progressive cognitive impairment. Dynamic disorders, myosmosis, ataxia, abnormal brain stem function, etc., which are divided into early onset LS and late onset LS, which can not be separated from age. In this paper, the clinical data of four patients with mitochondrial encephalomyopathy treated by our hospital were analyzed, and the skeletal muscle biopsy and mitochondrial total gene detection were performed, and the whole gene detection was determined. The value of the diagnosis of the disease. By summarizing and analyzing the published Leigh syndrome (LS) cases, the incidence of LS clinical symptoms and gene mutations in the respiratory chain enzyme complex, the correlation between the age of the disease and the type of gene mutation. The first part of the mitochondrial encephalomyopathy in four cases: clinical, pathological and genetic analysis: analysis of four cases of suspected clinical diagnosis The clinical data of patients with mitochondrial disease, skeletal muscle biopsy and mitochondrial total gene detection were used to determine the value of full gene detection in the diagnosis of the disease. Methods: four patients with suspected mitochondrial diseases were performed muscle biopsy and frozen enzyme histochemical staining. Four patients with 3ml peripheral blood were sequenced by mitochondrial whole gene and should be sequenced. Sanger sequencing, two generation sequencing, MLPA, CNV and other methods were used to detect MT DNA and N DNA. Results: 1. and four patients were involved in skeletal muscle weakness and exercise intolerance to varying degrees, symptoms were fluctuating and progressive; nervous system impairment was manifested as retardation, epilepsy, and other systems such as renal failure, instead of renal failure. The.CK value of metabolic acidosis, visual acuity, neurogenic deafness was normal or slightly higher, more than 1000U/L. Two cases of lactic acid exercise test were positive, two cases of other patients had increased lactate value.2., two cases of cranium MRS suggested that the damaged area of lactic acid peak.3. muscle biopsy showed that three patients were stained with broken red on MGT staining. Fiber (RRFs), the percentage of 10%--80%, COX staining suggested that the active part of the enzyme was missing. One case of muscle biopsy did not find specific RRF, but combined with clinical manifestations, imaging examination and gene detection confirmed mitochondrial encephalopathy.4. mitochondrial genome determination found that a patient was a large deletion mutation of mitochondrial cytochrome B gene, two The patient was a point mutation of mitochondrial nuclear gene, one patient did not find a clear pathogenicity mutation. Conclusion: 1. the genotype of mitochondrial encephalomyopathy, clinical phenotype with highly heterogeneous.2. clinical phenotype, imaging examination, muscle biopsy, gene detection is the basis for the diagnosis of mitochondrial encephalomyopathy. The second part of the patients with 385 cases of Leigh syndrome is clinical. Expression, gene mutation analysis objective: To evaluate the clinical manifestation of Leigh syndrome (Leigh syndrome, LS) through literature review, summarize the incidence of LS clinical symptoms and gene mutation of respiratory chain enzyme complex, the correlation between the age of the disease and the type of gene mutation. Methods: R2.15.3 software is used for Meta analysis. First, each of them is analyzed. The incidence of clinical symptoms was converted by logit, then the combination rate was calculated with the weight of samples. Finally, the combined "incidence" and its 95%CI. were tested by Homogeneity test (Q test) for heterogeneity test (the test level was alpha =0.1), and then I2 was used to determine the size of heterogeneity. If P0.10 and I250%, the results suggested the existence of the results. Heterogeneity, Meta analysis using random effect model, Meta analysis using fixed effect model, Eggers' test test for publication bias. Finally, the level of sensitivity analysis for sensitivity analysis of.Meta analysis by eliminating the minimum quality literature and re calculating the combination rate for.Meta analysis is the Mann-Whitney rank sum test and Kruskal-W of alpha =0.05.. Allis rank sum test was used to analyze the age difference between different gene mutations. The difference analysis of the incidence of common clinical symptoms was carried out with a double comparison of multiple rates of Pearson chi square test. The results were statistically different from P0.05. Results: a total of 385 cases of Leigh syndrome were collected in 5 articles. The Meta analysis of the clinical symptom merger rate was analyzed. The results showed that lactic acid increased by 62%, growth retardation 60%, muscular dystonia 47%, epilepsy 33%, ocular muscle damage and respiratory impairment 28%, muscle weakness 27%, and feeding difficulty 26%. The incidence of ataxia 20%. in different clinical symptoms was statistically significant, and the increase of lactic acid may be the earliest manifestation. Attention should be paid to early detection and early diagnosis. All LS patients should be diagnosed as early as possible. Gene sequencing, the age difference between the two genes of MT DNA and N DNA is statistically significant. The MT DNA gene mutation is more significant than the n DNA age.N DNA gene mutation site, the PDHA1 gene is late, and the age of the SLC19A3 gene is the earliest. The results of the mutation rate of the respiratory chain enzyme complex suggest the compound I 34%, compound IV 20%, complex I+IV 15% and complex V 9%. conclusion: the clinical manifestations of LS are varied, and the increase of lactic acid may be the most early manifestation. The age of the disease is related to the type of gene mutation, and the mutation of the respiratory chain enzyme complex is the most common cause of LS, and the common mutation of the complex I gene is common.

【學位授予單位】：山西醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R746

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