Download - Cylindrical Spirals associated with severe congenital muscle weakness and epileptic encephalopathy

Cylindrical Spirals associated with severe congenital muscle weakness and epileptic

encephalopathy

Edoardo Malfatti MD, PhD

1, Marcelo Chaves MD

2, Remi Bellance MD

3, Mai Thao Viou BSc

1, Elisabeth

Sarrazin MD3, Michel Fardeau MD1, and Norma B Romero MD, PhD1,4

1 Sorbonne Universités, UPMC Univ Paris 06, INSERM UMRS974, CNRS FRE3617, Center for Research in

Myology, GH Pitié-Salpêtrière, 47 Boulevard de l’hôpital, 75013 Paris, France

2 Buenos Aires Italian Hospital, Department of Neurology-Neuromuscular Disorders Centers, Buenos Aires,

Argentina.

3 Centre de Référence Caribéen des maladies neuromusculaire et neurologiques rares, CHU de Martinique.

4 Centre de référence de Pathologie Neuromusculaire Paris-Est, Institut de Myologie, GHU Pitié-Salpêtrière,

Assistance Publique-Hôpitaux de Paris; Paris, France

Acknowledgments

We are very grateful to our team of “Risler Lab”, their technical performance and secretarial assistance was

essential to the success of this work (M Beuvin, G Brochier, E Lacène, A Madeleine, and F Levy-Borsato).

This work was supported by the Institut National de la Santé et de la Recherche Médicale (INSERM), the

Association Française Contre les Myopathies (AFM), the Association Institut de Myologie (AIM) and the

Agence Nationale de la Recherche (ANR).

Corresponding Author:

Dr Norma Beatriz Romero, MD, PhD;

Institut de Myologie, INSERM UMR 974,

GHU La Pitié-Salpêtrière,

75013 Paris, France

E-mail: [email protected]

Tel: 33 (0) 1.42.16.22.42

Fax: 33 (0) 1.42.16.22.40

Running title: Infatile encephalomyopathy with cylindrical spirals

This article has been accepted for publication and undergone full peer review but has not beenthrough the copyediting, typesetting, pagination and proofreading process which may lead todifferences between this version and the Version of Record. Please cite this article as an‘Accepted Article’, doi: 10.1002/mus.24699

This article is protected by copyright. All rights reserved.

2

Cylindrical Spirals associated with severe congenital muscle weakness and epileptic

encephalopathy

Abstract

Introduction: Cylindrical spirals are characteristic muscular inclusions consisting of spiraling

double-laminated membranes. They are found in heterogeneous clinical conditions.

Results: We describe the presence of cylindrical spirals in muscle biopsies from 2 young sisters

with severe congenital hypotonia, muscle weakness, and epileptic encephalopathy.

Discussion: We report an association of a congenital encephalomyopathy with cylindrical spirals.

Through a detailed morphological and ultrastructural study, we speculate about the origin of these

peculiar structures.

Keywords: Neuromuscular disorders, neuropathology, congenital myopathy, inclusions, epileptic

encephalomyopathy, cylindrical spirals, electron microscopy

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John Wiley & Sons, Inc.

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Introduction

Cylindrical spirals (CSs) are well-defined inclusions, which are found rarely in muscle biopsies

from neuromuscular patients. Described originally by Carpenter et al. in 19791, they appear as

central or subsarcolemmal rounded inclusions staining bright red with the modified Gomori

trichrome staining (mGT) and dark blue with NADH and menadione alpha-glycerophospate

reaction. They are almost exclusively found in type 2 fibers2.

Electron microscopic analysis is fundamental for the recognition of these unique lesions and reveals

the presence of peculiar lamellar structures consisting of spiraling membranous whorls resembling

onion bulbs. CSs can be associated with other abnormal structures such as tubular aggregates3. For

this reason, it has been speculated that there is a common origin for tubular aggregates and

cylindrical spirals1. Since their first description they have been observed in a variety of

neuromuscular disorders without a common denominator. Some patients presented with muscle

weakness, pain, and cramps, but others have manifested a heterogeneous range of neurologic

conditions3-12

.

Until now CSs, with their unique appearance, are without parallel in muscle pathology. Their origin

is speculative, and their clinical significance remains unknown2.

We describe 2 sisters who presented with a severe congenital encephalomyopathy associated with

CSs in muscle, and we attempt to identify the early myopathological lesions leading to CSs

formation.

Material and methods

Morphological studies

An open muscle biopsy was performed in patients 1 and 2 (P1 and P2) and their mother after

obtaining informed consent. For conventional histochemical techniques 10 µm thick cryostat

sections were stained with hematoxylin and eosin (H&E), modified Gomori trichrome (mGT),

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Periodic acid Schiff (PAS), Oil red O, reduced nicotinamide adenine dinucleotide dehydrogenase-

tetrazolium reductase (NADH-TR), succinic dehydrogenase (SDH), Menadione-nitro blue

tetrazolium with α-glycerophospate, Cytochrome Oxidase (COX), and Adenosine triphosphatase

(ATPase) preincubated at pH 9.4, 4.63, and 4.35. Digital photographs of each biopsy were obtained

with a Zeiss AxioCam HRc linked to a Zeiss Axioplan bright field microscope and processed with

the Axio Vision 4.4 software (Zeiss, Germany).

Electron microscopy

Detailed electron microscopic analysis was performed in P1 and P2. Small muscle specimens were

fixed with glutaraldehyde (2.5%, pH 7.4), post-fixed with osmium tetroxide (2%), dehydrated, and

embedded in resin (EMBed-812, Electron Microscopy Sciences, USA). Ultra-thin sections from at

least 3 small blocks from each patient were stained with uranyl acetate and lead citrate. The grids

were observed using a Philips CM120 electron microscope (80 kV; Philips Electronics NV,

Eindhoven, The Netherlands) and were photographed using a Morada camera (Soft Imaging

System, France).

Results

Case Report

Patient 1, (P1) is a 12 year-old girl born from consanguineous French Antillean and Moroccan

parents. Pregnancy and delivery were uneventful. She presented with severe hypotonia at birth,

followed by the development of tonic-clonic and myoclonic epilepsy, and severe encephalopathy.

The seizures occurred frequently, were both generalized, complicated by cyanosis, or characterized

by bilateral clonic movements; they worsened with valproate and were only partially controlled

despite the use of multiple anticonvulsants (phenobarbital, carbamazepine, and levetiracetam).

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Clinical examination at age 5 years revealed severe hypotonia, global muscle weakness, and

amyotrophy. Psychomotor delay was severe; she never walked nor spoke. Brain MRI showed

bilateral frontal lobe atrophy. Cardiac examination was normal. Serum lactate was mildly elevated.

Molecular screening for common mitochondrial DNA (mtDNA) mutations and biochemical

analysis of respiratory chain complexes were normal. CGH-array was normal. Spinal muscular

atrophy (SMA), type 1 myotonic dystrophy (DM1), facioscapulohumeral muscle dystrophy

(FSHD1), and Prader-Willi syndrome were excluded.

The elder sister, patient 2 (P2), aged 13 years, was born at term after an uneventful pregnancy. She

had normal motor and mental development till age 7 months when she suddenly developed

progressive hypotonia and severe epileptic encephalopathy. On examination she displayed severe

hypotonia, muscle weakness, and mental retardation. The seizures occurred on a daily basis and

evolved from generalized to tonic-clonic and myoclonic. Multiple anticonvulsant therapy

(phenobarbital, carbamazepine, and levetiracetam) allowed adequate control of seizures.

Brain MRI showed bilateral frontal lobe atrophy. Cardiac examination was normal. Molecular

screening for common mitochondrial DNA (mtDNA) mutations and biochemical analysis of

respiratory chain complexes were normal. CGH-array was normal. SMN, DM1, FSHD, and Prader-

Willi syndrome were excluded.

There was no history of neuromuscular disorders in the family. The mother of our patients had

tonic-clonic seizures from age 20 years, which were treated successfully with valproate. Brain MRI

was normal apart from the presence of a right temporal lobe cyst.

Muscle morphology

A deltoid muscle biopsy from P1, performed at age 1 year, revealed the presence of inclusions

containing material staining bright red with the modified Engel-Gomori thrichrome tecnique. The

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inclusions were found in subsarcolemmal and central areas in around 15% of muscle fibers (Figure

1A). At higher magnification they appeared to be filled with sharply delineated clusters of granules,

presumably corresponding to transversely cut cylindrical spirals (Figure 1B). They reacted strongly

with NADH (Figure 1D) and menadione alpha-glycerophosphate (Figure 1E), but remained

unstained with both SDH (not shown) and COX (Figure 1F) stains. They were found only in type 2

fibers. ATPase stains revealed marked type 1 fiber predominance. Histopathological signatures of

mitochondrial disease such as ragged red fibers (RRFs) or COX-negative fibers were not observed.

Deltoid muscle biopsy in P2 performed at age 10 years revealed the same picture encountered in her

sister consisting of inclusions containing material staining bright red with the modified Gomori

thrichrome stain. The inclusions were found predominantly in subsarcolemmal regions of around

5% of muscle fibers (Figure 1C).

Ultrastructural analysis in P1 and P2 confirmed the presence of well-defined membrane-bound

inclusions spanning multiple sarcomeres and containing rounded and tubular profiles and located in

the central or subsarcolemmal areas of fibers (Figure 2A). Some of the tubular profiles were

vaguely reminiscent of partially formed tubular aggregates. One cluster contained around 50

cylindrical, spiralling structures composed of alternating dark and clear zones. The cylinders ranged

from 0.3 to 1 µ in diameter and up to 8 µ in length and were composed of 2 membranes with

vaguely periodic densities (Figure 2B). They formed a cistern containing cytoplasm bands probably

containing amorphous material. Each cylinder was composed of 6 to 20 lamellae. The central area

contained small vesicles and glycogen particles (Figure 2B). The width of the cisterns varied from

place to place, reflecting distortion or compression of these structures. Clusters of narrow elongated

tubules, either arrayed in stacks or separated, and apparently normal glycogen granules surrounded

the spirals. We failed to find continuity of the spirals with surrounding myofibrils. Search of

developmental stages in the makeup of the clusters revealed separate cylindrical units found

dispersed in intermyofibrillar spaces (Figure 2C). Organelles and structures surrounding the single

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spirals were normal (Figure 2C). Mitochondria were normal in size, shape, and distribution along

the sarcomeres.

A deltoid muscle biopsy from the mother of the patients, performed at age 34 years, did not reveal

any abnormalities.

Discussion

We report 2 young sisters who presented with CSs congenital myopathy associated with epileptic

encephalomyopathy. This is a novel clinical phenotype associated with the occurrence of CSs in

skeletal muscle.

Before our report CSs have been reported in 14 patients. Most were adults, the majority were men

(10 men, 4 women), and presented a large spectrum of clinical phenotypes (Table S1, available

online).

Seven cases were sporadic, and 6 had CSs associated with familial disorders. A common pattern of

inheritance is difficult to establish.

Our family has a likely recessive congenital myopathy as suggested by 2 affected siblings born to

consanguineous parents. The different degree of severity could be explained by some unknown

genetic factor.

Next generation sequencing analysis on DNA samples from the sisters and their parents is actually

ongoing in order to reveal an eventual molecular defect associated with this condition.

Since CSs myopathy is a pathological diagnosis at present, we reviewed the morphological features

of our patients with the objectives of refining their histological description and trying to trace

different stages leading to their formation.

CSs are found both in the center or subsarcolemmal areas of muscle fibers, often in the vicinity of a

myonucleus. Their frequency is highly variable, varying from 2% to 70% of muscle fibers.

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The modified Gomori thrichrome stain is the gold standard technique for their recognition. This

stain discloses sharply delimited bright red inclusions measuring approximately 1 µ in diameter.

Moreover, CSs react intensely with oxidative stains, exception for SDH and COX. Their

identification with the menadione alpha-glycerophosphate reaction (Figure 1E) helps distinguish

them from other structures such as tubular aggregates (TA). In fact, TAs are completely unstained

with SDH and only lightly stained with menadione alpha-glycerophosphate reaction. CSs are found

mainly in type 2 fibers, more frequently type 2B1, however Thomas et al

11 described the presence of

abundant CSs in type 1 fibers. Type 2 fibers constitutively own a more developed sarcoplasmic

reticulum. CSs may arise from this subcellular compartment in response to a metabolic/genetic or

toxic abnormalities.

Ultrastructurally, CSs consist of separated clusters of rounded profiles resembling a transversely cut

onion bulb2. One can imagined in 3D that they resemble a wool-ball. They are composed of 6 to 30

lamellae measuring around 1 µ in diameter, up to 10 µ in length. In some cases they have been

associated with tubular aggregates, mitochondrial alterations, or high lipid and/or glycogen content

(Table S1, available online).

Baker et al 12

described an infant with severe multisystem involvement due to D-2 hydroxyglutaric

aciduria and concentric laminated bodies or CSs in a muscle biopsy. Care should be taken to

distinguish between these 2 lesions. Concentric laminated bodies have a periodic structure

described as a ‘railway-like’ pattern reminiscent of the paracrystalline inclusions found in

degenerated mitochondria 13

. By contrast CSs do not have such a pattern. Moreover, concentric

laminated bodies have a more ovoid shape compared to CSs, and their membranes are concentric

instead of spiraling 13

.

The ultrastructural analysis of our cases failed to show any contiguity between CSs and native

myofilaments. In patient P1 we identified single CSs dispersed in intermyofibrillar spaces (Figure

2C). We speculate that these CSs could originate from a sarcoplasmic reticulum component from

which they successively proliferate and later form separate membrane-bound clusters. Some

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experimental evidence has shown that addition of Ca2 to a sonicated preparation of

phosphatidylserine in aqueous NaCl buffer led to the production of spiral shaped lipid cylinders that

successively coalesced into flattened sheets to form coiled elongated multilamellar cylinders6. An

acquired or genetic defect in calcium handling could be the mechanisms leading to CSs formation

in vivo.

On the other hand, a possible origin of CSs from degenerated mitochondria has been speculated14

.

With our detailed ultrastuctural analysis we failed to encounter any structure resembling

altered/degenerated mitochondria in the proximity of CSs, which disproves an eventual

mitochondrial derivation.

The significance of CSs and their impact on normal muscle function remain unknown. They may

arise as a result of specific genetic abnormality or represent an acquired nonspecific membranous

proliferation in response to various metabolic or toxic insults.

Only the identification of a genetic defect associated with these myopathies will help answer this

intriguing question.

In conclusion, with this report we describe a novel association of cylindrical spirals with early onset

muscle weakness and epileptic encephalomyopathy. Through a detailed morphological analysis we

tracked a possible sequence leading to the formation of membrane-bound separated clusters of CSs,

possibly originating from a sarcoreticular component in the muscular intermyofibrillar spaces.

Disclosures

Authors have nothing to disclose.

References

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1. Carpenter S, Karpati G, Robitaille Y, Memed C. Cylindrical Spirals in human skeletal

muscle. Muscle nerve 1979; 2: 282-7.

2. Engel AG, Banker BQ. Ultrastructural changes in diseased muscle. In: EngelAG, Franzini-

Amstrong C (eds) Myology, 2nd

edn. McGraw-Hill, New York, pp 944-946.

3. Danon MJ, Carpenter S, Harati Y. Muscle pain associated with tubular aggregates and

structures resembling cylindrical spirals. Muscle Nerve, 1989; 12: 265-72.

4. Bove KE, Iannaccone ST, Hilton PK, Samaha F. Cylindrical spirals in a familial

neuromuscular disorder. Ann Neurol, 1980; 7 (6): 550-6.

5. McDougal J, Wiles CM, Edwards RHT. Spiral membrane cylinders in the skeletal muscle of

a patient with melorheostosis. Neuroapthol. Appl Neurobiol. 1980; 6: 60-74.

6. Gibbels E, Henke U, Schadlich HJ, Haupt WF, Fiehn W. Cylindrical spirals in skeletal

muscle: a further observation with clinical, morphological, and biochemical analysis.

Muscle Nerve, 1983; 6 (9): 646-55.

7. Taratuto A, Matteucci M, Barreiro C, Saccolitti, Sevlever G. Autosomal dominant

neuromuscular disease with cylindrical spirals. Neuromuscular Disorders 1991; 1:433-441.

8. Rapuzzi S, Prelle A, Moggio M, Rigoletto C, Ciscato P, Comi G et al. High serum creatine

kinase levels associated with cylindrical spirals at muscle biopsy. Acta Neuropathol, 1995;

90 (6): 660-4.

9. Wolfe G, Burns D, Krampitz D, Barohn RJ. Cylindrical spirals of filamentous origin

associated with exertional cramps and Rhabdomyolysis. Neuromuscular Disorders 1997; 7:

536-538.

10. Yamamoto H, Sahashi K, Mizuno Y, Ibi T, Sobue G. A case of mitochondrial myopathy

with cylindrical spirals. Rinsho Shinkeigaku, 1982; 22 (3): 244-50.

11. Thomas PK, Workman JM, Thage O. Behr´s syndrome. A family exhibiting

pseudodominant inheritance. J Neurol Sci. 1984; 64: 137-148.

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12. Baker N, Sarnat H, Jack R, Patterson K, Shaw DW, Herndon SP. D-2-Hydroxyglutaric

aciduria: Hypotonia, cortical blindness, seizures, cardiomyopathy, and cylindrical spirals in

skeletal muscle. J Child Neurol 1997; 12: 31-36.

13. Fardeau M, and Tomé FMS. Non-neoplastic disorders of the skeletal muscle. In:

Johannessen JV. Electron microscopy in Human Medicine. Vol. 4. Soft tissues, bones and

joints. McGraw-Hill Inc. 1981 257-319.

14. Pavlovicova M, Novotova M, and Zahradnik I. Structure and composition of Tubular

Aggregates of Skeletal Muscle Fibers. Gne Physiol Biophys 2003; 22: 425-440.

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Figure Legends

Figure 1

Characteristic morphological alterations of skeletal muscle. (A) Modified Gomori trichrome stain

shows bright red inclusions in both central and subsarcolemmal areas of muscle fibers (Patient 1).

(B) At higher magnification the inclusions contain sharply delineated clusters or granules,

presumably corresponding to transversely cut cylindrical spirals (Patient 1). (C) Muscle sections

from patient 2 show bright red inclusions in subsarcolemmal areas. (D, E, F) Serial transverse

muscle sections from Patient 2. The inclusions corresponding to cylindrical spirals were found only

in type 2 fibers and stained darkly with both NADH and Menadione alpha-glycerophosphate

reactions (D, and E, indicated by a star). The inclusions did not stain with COX histochemical

reaction (F). Scale-bars in A-D correspond to 5 µm.

Figure 2

Elecron microscopy. (A) A subsarcolemmal membrane-bound inclusion containing numerous

(around 20) cylindrical spirals and tubular profiles surrounded by glycogen granules. (B)

Cylindrical spiral measuring 1µm long and 8µm in diameter composed of 2 membranes showing

vaguely periodic densities. The central area of the cylinder contains small vesicles and glycogen

particles. (C) Single units of cylindrical spirals encountered in different intermyofibrillar spaces.

The mitochondria contiguous to the spirals and in other intermyofibrillar spaces have normal size

and morphology.

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400x500mm (300 x 300 DPI)

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Elecron microscopy. (A) Subsarcolemmal membrane bound inclusion containing numerous (around 20) cylindrical spirals and

tubular profiles surrounded by glycogen granules.

(B) Cylindrical spiral measuring 1µm long and 8µm of diameter composed by two membranes showing vaguely periodic densities. The central area of the cylinder contains small vesicles and glycogen particles. (C) Single units of cylindrical spirals encountered in different intermyofibrillar spaces. The mitochondria contiguous to the spirals, and in other intermyofibrillar spaces present a normal size, and morphology.

266x355mm (300 x 300 DPI)

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Table S1. Comparison of published cases with Cylindrical spirals. H: histochemistry; EM:

electron microscopy. ND: not determined.

Author Age Gender

Family history

Biopsied muscle

Cylindrical spirals features

Other features Symptoms Serum CK

Reported Diagnosis

Carpenter et al. [1]

53 M ND Left gastrocnemius,

left sural, left biceps

H: sharply delimited clusters of small bright red granules/rings

(mGT) of 1µm in 30% of type 2 fibers

EM: rounded profiles composed of

alternating dark and clear zones of 50‐110 nm of diameter. Spirals composed by 9 to 15

lamellae

EM: tubular aggregates

Muscle cramps ND Malignancy

Carpenter et al. [1]

53 M Gait disorders Left gastrocnemius

H: sharply delimited clusters of small bright red granules/rings

(mGT) of 1µm in 30% of type 2 fibers

EM: rounded profiles composed of

alternating dark and clear zones of 50‐110 nm of diameter. Spirals composed by 9 to 15

lamellae

EM: subsarcolemmal mitochondrial aggregates with paracristalline inclusions

Progressive gait ataxia

ND Heredofamiliar spinocerebellar degeneration

Bove et al. [4]

31 F Mother of patient below

Quadriceps H: subsarcolemmal aggregates/granules

staining dark‐blue/purple (mGT) in 25‐50% of muscle

fibers EM: Spirals 8µm long

1µm diameter composed by 10‐16

lamellae

No Exertional cramps Normal Percussion myotonia

Bove et al. [4]

10 M Son of patient above

Biceps H: subsarcolemmal granules staining dark‐blue purple (mGT), in 10% of muscle fibers

No ND Normal Percussion myotonia

Mc Dougal et al. [5]

20 M ND Left and right quadriceps

H: granular round red (mGT) material in peripheral or

perinuclear areas in about 2% of fibers EM: Uniformly

oriented cylinders, 0.3‐1.5 µm diameter and 2.5µm or more long

No Pain and weakness of left thigh

ND Melorheostosis

Yamamoto et al. [10]

27 M ND ND ND ND Pain and cramps of proximal leg muscles

ND Abnormal muscle

mitochondria Gibbels et al. [6]

60 M ND Bilateral brachioradial, extensor carpi radial, long peroneal

H: Clusters of small subsarcolemmal and perinuclear granules composed by smaller

particles heavily stained with mTG in

64% of type 2B muscle fibers

EM: spiral laminated cylindrical structures usually 2µm in length, 0.5‐2µm diameter. 6‐28 mean 12 lamellae

Single degenerating

spirals resembling concentric

lamellating bodies and myelin‐like

bodies

Wasting of forearm muscles, aching of

legs

Normal Alcoholism, diabetes,

polyneuropathy


2

Danon et al. [3]

42 M ND Quadriceps H: red sarcolemmal accumulations (mTG)

in 20% of fibers EM: Round sacs of

0.18µm. Spiral pattern never found

Tubular aggregates

Severe leg pain, transient episodic

weakness

Normal Dementia

Thomas et al. [11]

25 W Familial Behr syndrome

Quadriceps H: discrete focal fuchsinophilic inclusion in subsarcolemmal regions (mGT) or

within the substance of fibers

EM: cylindrical membranous

structures particularly in Type 1 fibers. 0.8 µ diameter. 10‐30µm in

length. Up to 30 lamellae. Mainly

orientated on the axis of the muscle fiber

Mitochondrial accumulation, mitochondrial paracrystalline inclusions

Pyramidal weakness, dysarthria, ataxia

Normal Behr syndrome Optic atrophy,

mental deterioration, nystagmus

Taratuto et al. [7]

70 W Muscle weakness, gait disorder, motor impairment, scoliosis

Biceps H: large rod‐like or granular bright red inclusions (mTG)

measuring 1 to 5µm in type 2 fibers

EM: Cylindrical spiral measuring 1‐5µm in diameter and 10µm in

length. Up to 12 lamellae

Dilatation of terminal cisternae

Leg weakness High Autosomal dominant

neuromuscular disease

Taratuto et al. [7]

52 M Muscle weakness, gait disorder, motor impairment

Left and right quadriceps

H: bright red inclusions (mTG) in 28% of type 2

fibers. Clusters extended up to 300µm

length EM: Cylindrical spiral measuring 1‐5µm in diameter and 10µm in

length. Up to 12 lamellae

Inclusions recalling RRFs or rimmed vacuoles

Leg weakness, gait instability

High Autosomal dominant

neuromuscular disease

Rapuzzi et al. [8]

30 M ND Right quadriceps

H: subsarcolemmal and intermyofibrillar

granular bright red inclusions (mGT) in 70% of type 2 muscle

fibers EM: 50 to 110 nm

cylinders of spiraling membranes

No ND High Elevated serum creatine kinase

Wolfe et al. [9]

31 M Myoglobinuria after exercise

Quadriceps H: subsarcolemmal and central darkly

basophilic, granular accumulations bright‐red (mGT) in Type 2

fibers EM: 30 lamellae wrapped around a

central core

No Exertional cramps and rhabdomyolisis

High Schizophrenia, myoglobinuria

Baker et al. [12]

4m W History of a brother dead at

birth after normal

pregnancy

Vastus lateralis Concentric laminated bodies or cylindrical

spirals

Excessive glycogen content, and lipid

surcharge

Hypotonia, seizures, cardiomyopathy

ND D‐2‐hydroxyglutaric

aciduria

Malfatti et al. (present case)

12 W Sister of patient below

Left deltoid H: subsarcolemmal and central bright red (mGT) inclusions in 15% of type 2 muscle fibers. Strongly stained

with NADH and menadione alpha‐

No Muscle hyoptonia, epilepsy,

psychomotor delay

Normal Congenital myopathy with

epileptic encephalopathy


3

glycerophosphateEM: well‐defined membrane bound

rounded and tubular profiles. Cylinder

measured 1µm long and 8 µ of diameter

Malfatti et al. (present case)

13 W Sister of patient above

Left deltoid H: subsarcolemmal, and central bright red in 5% of type 2 muscle fibers. Strongly stained

with NADH and menadione alpha‐glycerophosphate EM: well‐defined membrane bound

rounded and tubular profiles. Cylinder

measured 1µm long and 8µm of diameter

No Muscle hypotonia, epilepsy,

psychomotor delay

Normal Congenital myopathy with

epileptic encephalopathy
