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Clinical Spectrum, Morbidity, and Mortality in 113 Pediatric Patients With Mitochondrial Disease

Fernando Scaglia, MD^*,, Jeffrey A. Towbin, MD^,, William J. Craigen, MD, PhD^*,, John W. Belmont, MD, PhD^*,, E. O’Brian Smith, PhD, Stephen R. Neish, MD^,, Stephanie M. Ware, MD, PhD^*,, Jill V. Hunter, MBBS^,||, Susan D. Fernbach, RN^*,, Georgirene D. Vladutiu, PhD^¶, Lee-Jun C. Wong, PhD^# and Hannes Vogel, MD^**

^* Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
Texas Children’s Hospital, Houston, Texas
Department of Pediatrics, Baylor College of Medicine, Houston, Texas
^|| Department of Radiology, Baylor College of Medicine, Houston, Texas
^¶ Department of Pediatrics, School of Medicine & Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
^# Institute for Molecular and Human Genetics, Georgetown University Medical Center, Washington, DC
^** Department of Pathology, Stanford University, Stanford, California

Objectives. The aim of this study was to elucidate the frequency of major clinical manifestations in children with mitochondrial disease and establish their clinical course, prognosis, and rates of survival depending on their clinical features.

Methods. We performed a retrospective review of the medical records of 400 patients who were referred for evaluation of mitochondrial disease. By use of the modified Walker criteria, only patients who were assigned a definite diagnosis were included in the study.

Results. A total of 113 pediatric patients with mitochondrial disease were identified. A total of 102 (90%) patients underwent a muscle biopsy as part of the diagnostic workup. A significant respiratory chain (RC) defect, according to the diagnostic criteria, was found in 71% of the patients who were evaluated. In this cohort, complex I deficiency (32%) and combined complex I, III, and IV deficiencies (26%) were the most common causes of RC defects, followed by complex IV (19%), complex III (16%), and complex II deficiencies (7%). Pathogenic mitochondrial DNA abnormalities were found in 11.5% of the patients. A substantial fraction (40%) of patients with mitochondrial disorders exhibited cardiac disease, diagnosed by Doppler echocardiography; however, the majority (60%) of patients had predominant neuromuscular manifestations. No correlation between the type of RC defect and the clinical presentation was observed. Overall, the mean age at presentation was 40 months. However, the mean age at presentation was 33 months in the cardiac group and 44 months in the noncardiac group. Twenty-six (58%) patients in the cardiac group exhibited hypertrophic cardiomyopathy, 29% had dilated cardiomyopathy, and the remainder (13%) had left ventricular noncompaction. Patients with cardiomyopathy had an 18% survival rate at 16 years of age. Patients with neuromuscular features but no cardiomyopathy had a 95% survival at the same age.

Conclusions. This study gives strong support to the view that in patients with RC defects, cardiomyopathy is more common than previously thought and tends to follow a different and more severe clinical course. Although with a greater frequency than previously reported, mitochondrial DNA mutations were found in a minority of patients, emphasizing that most mitochondrial disorders of childhood follow a Mendelian pattern of inheritance.

Key Words: mitochondrial encephalomyopathies • mitochondrial cardiomyopathies • modified Walker criteria • morbidity • survival rate

Abbreviations: RC, respiratory chain • mtDNA, mitochondrial DNA • SDH, succinate dehydrogenase • MELAS, mitochondrial encephalopathy with lactic acidosis and stroke-like episodes • MERRF, myoclonic epilepsy with ragged red fibers • NARP, neuropathy, ataxia, and retinitis pigmentosa • LHON, Leber hereditary optic neuropathy • MNGIE, mitochondrial neurogastrointestinal encephalomyopathy • LVNC, left ventricular noncompaction • HCM, hypertrophic cardiomyopathy • NADH-TR, nicotinamide adenine dinucleotide-tetrazolium reductase

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