Objective: Some pathologic features of the FHL1 myopathies and the myofibrillar myopathies (MFMs) overlap; we therefore searched for mutations in FHL1 in our cohort of 50 patients with genetically undiagnosed MFM.
Methods:Mutations in FHL1 were identified by direct sequencing. Polymorphisms were excluded by using allele-specific PCR in 200 control subjects. Structural changes in muscle were analyzed by histochemistry, immunocytochemistry, and electron microscopy.
Results:We detected 2 novel and 1 previously identified missense mutation in 5 patients. Patients 1-4 presented before age 30, display menadione-nitro blue tetrazolium-positive reducing bodies, and harbor mutations in the FHL1 LIM2 domain. Patient 5 presented at age 75 and has no reducing bodies, and his mutation is not in a LIM domain. The clinical features include progressive muscle weakness, hypertrophied muscles, rigid spine, and joint contractures, and 1 patient also has peripheral neuropathy. High-resolution electron microscopy reveals the reducing bodies composed of 13-nm tubulofilaments initially emanating from Z-disks. At a more advanced stage, abundant reducing bodies appear in the cytoplasm and nuclei with concomitant myofibrillar disintegration, accumulation of cytoplasmic degradation products, and aggregation of endoplasmic reticulum and sarcotubular profiles. The four-and-a-half LIM domain protein 1 (FHL1), encoded by FHL1, is located on Xq26.3. It is highly expressed in skeletal and cardiac muscle and less abundantly in brain, placenta, lung, liver, kidney, pancreas, and testis.1-3 Mutations in FHL1 have been associated with diverse chronic myopathies. 4 These include late-onset X-linked scapulo-axio-peroneal myopathy with bent spine syndrome, 5 reducing body myopathy, 6,7 X-linked dominant scapuloperoneal muscular dystrophy, 8 rigid spine syndrome, 9 and contractures and cardiomyopathy mimicking Emery-Dreifuss muscular dystrophy. 10,11 Most FHL1 mutations appear in the second or fourth LIM domains with a single mutation in the third LIM domain.Myofibrillar myopathies (MFMs) arise from primary degeneration of the muscle fibers and represent a morphologically distinct but genetically heterogeneous subset of muscular dystrophies. The unifying histologic findings are early disintegration of the Z-disk followed by myofibrillar disintegration, aggregation of degraded filaments into pleomorphic granular or hyaline inclusions, and ectopic expression of multiple Z-disk-related and other proteins in the affected muscle fibers.12-14 Although some pathologic features of the FHL1 muscular dystrophies and the MFMs overlap, reducing bodies have been detected only in FHL1 dystrophies. 7,15 We here report 2 novel