Molecular Genetics of Inclusion Body Myositis and Late-Onset Rimmed-Vacuolar Distal Myopathy

Molecular genetics of late-onset neuromuscular diseases is often challenging to study due to limited patient and family material. This thesis aimed to unravel the genetics of late-onset myopathy patients with inclusion body myositis (IBM) and yet unknown inherited distal myopathy phenotype.

IBM is an inflammatory myopathy of idiopathic nature showing characteristic quadriceps and finger flexor muscle weakness and rimmed vacuolar pathology. The molecular etiology of IBM is of key interest due to co-existing cytotoxic T-cell activity. However, the precedence of degenerative pathology and autoimmune features remain unclear, hampering the eventual development of appropriate therapeutic options. Using DNA and RNA sequencing-based data analysis, we aimed at understanding the different components of the molecular pathomechanisms in IBM. Using a limited case-control study, we identified the association of HLA-DQB1 in Finnish IBM patients. Additionally, by performing a comprehensive transcriptomics analysis we observed differential expression and splicing patterns in genes associated with maintaining calcium homeostasis, particularly during different T-cell activity and regulation stages. Disturbed antigen-driven T-cell hyperactivity and eventual loss of T-cell apoptosis could be one of the mechanisms behind the refractoriness of immune therapies in IBM patients.

Patients with late-onset rare diseases often experience a long diagnostic journey in multiple and often invasive diagnostic procedures and ineffective symptomatic treatments. Due to limited study material, it is often difficult to ascertain the molecular diagnosis of previously unknown inherited myopathies. Identifying new rare disease-causing genes requires collaborations from different diagnostic centers, sharing deep phenotypic and genomic data. We identified a novel type of slowly progressing late-onset distal myopathy with rimmed vacuoles caused by mutations in the small muscle protein X-linked (SMPX) gene in patients from five different countries. Our genetic analysis revealed four different missense mutations, including two different founder mutations in Europe, indicating that the prevalence of this disease may be higher, and therefore SMPX should be considered in all unsolved male patients with late-onset rimmed vacuolar myopathy.