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A miopatia miotubular é uma doença genética congênita que afeta a musculatura esquelética e respiratória, causada por mutações no gene MTM1. Apresenta padrão de herança recessivo ligado ao cromossomo X e frequência estimada de 1/50.000 meninos nascidos vivos. O diagnóstico é geralmente realizado através de biopsia muscular, com presença de fibras pequenas com núcleo central, predominância de fibras do tipo I, concentração de miofibrilas na periferia da fibra e região central ocupada por acúmulos de mitocôndrias e glicogênio. O quadro clínico é bastante grave, com manifestação clínica no período neonatal e óbito nos primeiros meses, ou ano de vida. Os pacientes apresentam hipotonia e fraqueza muscular generalizadas, dificuldade de alimentação, ptose palpebral, oftalmoplegia, hérnia inguinal e criptorquidia. Mulheres portadoras das mutações são geralmente assintomáticas, mas diversos casos de heterozigotas sintomáticas têm sido relatados. Pacientes com miopatias congênitas estruturais vem sendo estudados nos últimos 20 anos no Centro de Pesquisa do Genoma Humano e Células Tronco (CPGH-CEL) da Universidade de São Paulo (USP). Atualmente, em razão do avanço das tecnologias de análise molecular do DNA, como o sequenciamento de nova geração (NGS - Next Generation Sequencing), o diagnóstico tem se tornado cada vez mais preciso. No presente trabalho, pacientes de 12 famílias estudadas no CEGH-CEL foram submetidos à triagem mutacional, utilizando técnica de NGS. Onze mutações foram identificadas (c.109 C>T; c.139_142 delAAAG; c.706 A>T; c.1010 G>A, c.1181 A>G, c.1262 G>A, c.1354 -1 G>C, c.1465_1465delC, c.1467 +1 G>A, c.1528 A>T; c.1528 A>T); entre elas 5 já descritas como patogênicas e 6 são novas. Em duas famílias, foram identificadas 4/8 e 2/4 mulheres portadoras apresentando algum nível de manifestação clínica. A análise de desvio de inativação do X revelou desvio aleatório em pelo menos 4 das heterozigotas manifestantes. Além disso, adicionando os casos deste trabalho aos relatados na literatura, a taxa de penetrância da doença foi estimada em 30% em mulheres heterozigotas, o que é compatível com um padrão de penetrância incompleta e poderia explicar a alta frequência de mulheres manifestantes. Uma análise de exomas foi realizada a fim de identificar possíveis genes modificadores que explicassem a variabilidade clínica observada. Foi identificada uma região de 4,2 Mb contendo genes contíguos no cromossomo 19 que pode estar relacionado à modulação do fenótipo / Myotubular myopathy is a rare congenital muscle genetic disease, caused by mutations in the MTM1 gene. With a X-linked recessive inheritance, the disease affects 1/50.000 living born males. The clinical picture is characteristic and very severe, with manifestation in the neonatal period, including generalized hypotonia and muscle weakness, feeding difficulty, palpebral ptosis, ophthalmoplegia, inguinal hernia, and cryptorchidism. Most affected die in the first few months or year of life, and those who survive often depend on care and assistance to perform activities of daily living, as well as require mechanical ventilation and enteral nutrition. Females carrying the mutations are generally asymptomatic, but several cases of symptomatic heterozygotes have been reported, compared to the low frequency of manifesting carriers in other X-recessive diseases. Patients with structural congenital myopathies have been studied in the last 20 years at the Human Genome and Stem Cell Research Center (HUG-CELL) at the University of São Paulo (USP). The diagnosis of myotubular myopathy is usually made with muscle biopsy findings, with small fibers with central nuclei, the predominance of type I fibers, the concentration of myofibrils in the periphery of the fiber and central region occupied by accumulations of mitochondria and glycogen. More recently, with the advancement of DNA molecular analysis technologies, such as Next Generation Sequencing (NGS), the diagnosis has become increasingly accurate. In the present study, patients from 12 families studied in the HUG-CEL were submitted to mutation screening using NGS techniques. Eleven mutations were identified (c.109 C> T; c.139_142 delAAAG; c.706 A> T; c.1010 G> A, c.1181 A> G, c.1262 G> A, c.1354-1 G> C, c.1465_1465delC, c.1467 +1 G> A, c.1528 A> T; c.1528 A> T); among them 6 are novel. In two families, 4/8 and 2/4 female carriers were identified, presenting some level of clinical manifestation. Inactivation skewing analysis of the X chromosome revealed random inactivation in at least 4 of the manifesting carriers. In addition, joining the cases of this work to those reported in the literature, the disease penetrance rate was estimated to be 30% in heterozygous women, which is compatible with an incomplete penetrance pattern and could explain the high frequency of manifesting females. An exome analysis was performed to identify possible modifying genes that explain the observed clinical variability. A region of 4,2 Mb containing contiguous genes was identified on chromosome 19 that may be related to phenotype modulation

Des mutations dans les gènes codant pour des myotubularines (MTM) sont responsables de maladies neuromusculaires telles que la XLCNM (MTM1) ou la CMT4 (MTMR2 & MTMR13). Les MTMs sont des phosphatases à phosphosinositides (PPIn), des messagers lipidiques essentiels pour la régulation spatio-temporelle de fonctions cellulaires vitales.La présence de 14 paralogues de MTMs chez l’Homme complique l’analyse de la fonction cellulaire d’un seul membre de la famille. La levure Saccharomyces cerevisiae, dont l’organisation cellulaire est comparable à une cellule humaine, ne compte en revanche qu’un seul homologue de MTM (YMR1), pour lequel nous disposons de mutants de délétion viables.L’expression de MTM1 sauvage ou mutants de patients dans la levure montre seules les myotubularines enzymatiquement actives induisent une morphologie anormale du compartiment lysosomal et un défaut du trafic membranaires endocytique.Nos résultats suggèrent que l’activité phosphatase de MTM1 ne serait pas à elle seule responsable de la XLCNM mais que d’autres mécanismes, tels que les interactions protéiques, pourraient prendre part au développement de la maladie. / Mutations in myotubularin (MTM) genes are responsible for neuromuscular diseases like the XLCNM (MTM1) or the CMT4B (MTMR2 & MTMR13). MTMs dephosphorylate phosphoinositides (PPIn), lipid messengers that play an essential role in the spatio-temporal regulation of critical cellular functions.The presence of 14 MTMs paralogues in Human hinders the analysis of the cellular function of a single MTM family member. The yeast Saccharomyces cerevisiae displays an intracellular organization that is similar to human cells and its genome encodes for only one myotubularin (YMR1) for which deletion mutants are available and viable.The expression of MTM1 either wild-type or mutants from patients, in yeast, shows that only phosphatase-active myotubularins induce an abnormal morphology of the lysosomal compartment and a defect in the endocytic membrane trafficking.Our results suggest that the catalytic activity of MTM1 isn’t single-handedly responsible for XLCNM but that other mecanisms, such as protein-protein interactions, could take part in the development of the disease.

Le couplage excitation-contraction (EC) du muscle squelettique correspond à l’efflux de Ca2+ par le réticulum sarcoplasmique (RS) suite à une dépolarisation sarcolemmale. Des mutations dans les gènes MTM1 et DNM2 sont responsables respectivement de la forme sévère et modérée de la myopathie centronucléaire (CNM). Chez la souris Mtm1 KO, l’absence de la (PtdInsP) 3-phosphatase MTM1 est associée à une altération du couplage EC, propablement la cause majeure de la faiblesse musculaire. Le rôle du PdtIns(4,5)P2 dans la régulation du couplage EC a été étudié dans des fibres musculaires exprimant une PtdInsP phosphatase sensible au potentiel. Grâce à une combinaison d’électrophysiologie et d’imagerie confocale, nous avons montré une altération de l’efflux calcique en réponse à de fortes dépolarisations déplétant les stocks de PdtIns(4,5)P2 à la membrane.Dans un deuxième temps, une caractérisation complète des défauts de signalisation calcique et du couplage EC a été réalisée dans les fibres musculaires isolées de souris Mtm1 KO. Nos résultats indiquent que l’efflux calcique est d’amplitude réduite, est retardé et est spatialement hétérogène. L’inhibition pharmacologique de l’activité PtdInsP 3-kinase améliore ces défauts in vitro et la survie des souris in vivo, suggérant que l’accumulation des substrats de MTM1 participe au défaut du couplage EC. Ces résultats montrent le bénéfice thérapeutique d’une approche pharmacologique aux inhibiteurs d’activité PtdInsP 3-kinase.Enfin, nous avons montré que les fibres musculaires d’un modèle murin de la forme modérée de CNM (KI-Dnm2R465W) partagent certaines altérations du couplage EC avec le modèle Mtm1 KO (retard de l’efflux calcique) pouvant contribuer à la faiblesse musculaire. Cependant, d’autres défauts (altérations structurales, réduction de l’efflux calcique) affectent plus sévèrement le modèle Mtm1 KO, et pourraient être déterminants dans la différence de sévérité entre les deux formes de CNM / Excitation-contraction (EC) coupling is the process whereby a membrane depolarization leads to an increased cytosolic Ca2+ content, allowing contraction. Mutations in the genes MTM1 and DNM2 are responsible respectively for severe and moderate forms of centronuclear myopathy (CNM). In Mtm1 KO mouse model, MTM deficiency is associated with defective EC coupling, which makes probably the major contribution to muscle meakness.PdtIns(4,5)P2 involvement in regulating EC coupling has been investigated in muscle fibers expressing a voltage sensing PtdInsP phosphatase. Thanks to a combination of electrophysiology and confocal imaging techniques, we showed a reduction of SR Ca2+ release amplitude in response to strong depolarizations activating PdtIns(4,5)P2 depletion at plasma membrane.Secondly, we made a complete characterization of calcium signaling and EC coupling properties in isolated muscle fibers from Mtm1 KO mice. Our results demonstrate that SR Ca2+ release is depressed, delayed and spatially heterogeneous in diseased fibers. Moreover, we showed that pharmacological inhibition of PtdInsP 3-kinase activity improves these defects in vitro and mice survival in vivo, suggesting that accumulation of MTM1 substrates may participate to defective EC coupling. Overall, these results provide proof of concept for the use of PtdIns 3-kinase inhibitors in severe form of CNM.Finally, we showed that muscle fibers from murine model of moderate CNM form (KI-Dnm2R465W) share some of EC coupling defects with Mtm1 KO model (delayed SR Ca2+ release) that may contribute to muscle weakness. However, other defects (structural alterations, depressed SR Ca2+ release) affect more severely Mtm1 KO model, and may be critical in determining the severity of CNM

La myopathie myotubulaire est une maladie musculaire congénitale très sévère. Le laboratoire d’accueil a démontré que les échantillons de muscle de patients atteints de cette maladie ainsi que le modèle murin présentent une surexpression de DNM2, alors que sa réduction par croisement génétique améliore les signes cliniques et histologiques de la maladie. Le but de ce travail consistait à développer, tester et valider des composés injectables qui ciblent DNM2 et diminuent son niveau. Deux approches thérapeutiques ont été développées l’une basée sur l’utilisation de virus adéno-associés (AAV) exprimant des shRNA, l’autre sur les oligonucleotides antisens (ASO). L’injection des vecteurs AAV-shDnm2 ou bien les ASO-Dnm2 pouvait corriger les défauts histologiques et fonctionnels des muscles des souris myopathes.Les résultats obtenus montrent le potentiel thérapeutique de la réduction de DNM2, et présente une nouvelle approche pour le traitement de la myopathie myotubulaire. / Myotubular myopathy is a severe muscle disease. We previously have shown that muscle specimens of both patients and the mouse model presented an overexpression of DNM2, while its genetic reduction prevents the development of the muscle phenotypes. The aim of this work was to develop, test and validate deliverable compounds. Two therapeutic approaches were used. Injection of antisense oligonucleotide or adeno-associated virus expressing shRNA restores a normal lifespan with improved muscle structure and function of the myopathic mice. These results demonstrate that therapeutic potential of reduction of DNM2 level and provides an attractive therapeutic strategy that could be applied to treat myotubular myopathy.

Centronuclear myopathy (CNM) is a genetically heterogeneous disorder associated with general skeletal muscle weakness, type I fiber predominance and atrophy, and abnormally centralized nuclei. Autosomal dominant CNM is due to mutations in the large GTPase dynamin 2 (DNM2), a mechanochemical enzyme regulating cytoskeleton and membrane trafficking in cells. To date, 40 families with CNM-related DNM2 mutations have been described, and here we report 60 additional families encompassing a broad genotypic and phenotypic spectrum. In total, 18 different mutations are reported in 100 families and our cohort harbors nine known and four new mutations, including the first splice-site mutation. Genotype-phenotype correlation hypotheses are drawn from the published and new data, and allow an efficient screening strategy for molecular diagnosis. In addition to CNM, dissimilar DNM2 mutations are associated with Charcot-Marie-Tooth (CMT) peripheral neuropathy (CMTD1B and CMT2M), suggesting a tissue-specific impact of the mutations. In this study, we discuss the possible clinical overlap of CNM and CMT, and the biological significance of the respective mutations based on the known functions of dynamin 2 and its protein structure. Defects in membrane trafficking due to DNM2 mutations potentially represent a common pathological mechanism in CNM and CMT.

La myopathie myotubulaire (XLMTM, OMIM 310400) est causée par des mutations dans le gêne MTM1 situé sur le chromosome X et apparaît à une fréquence de 1/50 000 naissances mâles. Les patients présentent une hypotonie et une faiblesse musculaire généralisées et de graves problèmes respiratoires à la naissance. En absence de traitement, les patients sont nombreux à décéder durant la première année de vie. Mon travail de thèse consiste à développer un traitement de thérapie génique pour la myopathie myotubulaire. L'injection intraveineuse du vecteur thérapeutique rAAV9-DES-Mtm1 chez le modèle murin de la myopathie myotubulaire permet d'obtenir de la protéine transgénique dans l'ensemble des muscles squelettiques de l'organisme. Un an après le traitement, les muscles malades retrouvent une morphologie normale et les souris sont en vie. La seconde partie porte sur l'évaluation des effets de la protéine MTMR2, un homologue de la myotubularine (MTM1), sur le muscle déficient en myotubularine, comme alternative à la thérapie génique avec MTM1. L'administration d'un vecteur AAV comportant le transgène MTMR2 dans le muscle malade améliore, partiellement, le phénotype musculaire. Ces résultats suggèrent que l'augmentation du niveau d'expression de MTMR2 dans le muscle malade pourrait être un traitement efficace. Enfin j'ai étudié le rôle de l'activité phosphatase de la myotubularine dans son action thérapeutique. J'ai comparé l'effet d'une forme inactive de myotubularine (MTMIC375S) à celui du transgène thérapeutique sur le muscle atteint de myopathie myotubulaire. Les résultats montrent que l'activité phosphatase de la myotubularine est nécessaire pour son activité thérapeutique. / Myotubular myopathy (XLMTM, OMlM 310400) is caused by mutations in the MTM1 gene located on the X chromosome and appeared at a frequency of 1/50 000 male births. Most of the patients arc affected by hypotonia and generalized muscular weakness as weIl as grave respiratory problems in the birth. In absence of an effective therapeutic treatment they are many to die during the first year of their life. My thesis work consists in developing a treatment of gene therapy for myotubular myopathy. The intravenous injection of the therapeutic vector rAAV9-DES-MTM1 into the murin model of the myotubular myopathy allows transgenic protein in the whole skeletal muscle of the body. The therapeutic protein cures the muscular phenotype rapidly after injection. At one year after treatment, the thick muscles still be cured, mice are alive and recovered a normal development. Then, I estimated the effects of the protein MTMR2, a counterpart of the myotubularine (MTM1), on muscles from mice devoid of myotubularin, as alternative at the gene therapy with MTM1. The administration of a vector AAV containing the transgene MTMR2 in the thick muscles improves, partially, the muscular phenotype. These results suggest that the increase of MTMR2 protein level MTMR2 thick muscle could be an effective treatment. Finally, I studied the role of myotubularin phosphatase activity on its therapeutic action, I compared the effect of an inactive shape of myotubularin (MTM1C375S) on muscle affected by myotubular myopathy as the effect of therapeutic transgene on the same muscle. The results show that the phosphatase activity of the myotubularin is necessary for its therapeutic activity.

Les myopathies centro-nucléaires (CNM) sont un groupe de maladies musculaires sévères caractérisées par une faiblesse musculaire générale. La forme la plus sévère est la CNM liée à l’X (XLCNM), causée par des mutations de la Myotubularine (MTM1). D’autres formes autosomales existent et sont causées par des mutations de l’Amphiphysine2 (BIN1) et de la Dynamine2 (DNM2). Les mécanismes pathologiques menant aux CNMs restent à éclaircir et à ce jour aucune thérapie n’est disponible pour traiter les patients. Nous avons modulé les niveaux de protéines de MTM1, BIN1 et DNM2 dans des modèles murins de CNMs. Nous avons découvert que la sous-régulation de DNM2 sauvait le modèle murin de XLCNM et que la sur-expression de la protéine BIN1 humaine sauvait le modèle murin XLCNM ainsi que la forme autosomale causée par les mutations DNM2. Nous avons montré que MTM1 contrôlait l’adhésion cellulaire et le recyclage de l’intégrine dans les cellules musculaires. Nous avons observé que la sur-expression de BIN1 sauvait la dérégulation du recyclage de l’intégrine dans le modèle murin de XLCNM, ce qui suggère un lien fonctionnel entre BIN1 et MTM1 nécessaire pour l’adhésion focale au niveaux musculaire. Notre étude montre que MTM1, BIN1 et DNM2 participe à une voie de signalisation commune et que BIN1 et DNM2 représentent de nouvelles cibles thérapeutiques pour le traitement des CNM. / Centronuclear myopathies (CNM) are a group of severe muscle disorder characterized by general muscle weakness. The most severe form is the X-linked CNM (XLCNM), caused by mutations in Myotubularin (MTM1). Others autosomal forms are caused by mutations in Amphiphysin 2 (BIN1) and Dynamin 2 (DNM2). The CNM pathomechanisms are still unclear and to date there are no therapies available to the disease. To investigate the pathways dysregulated in CNM and to identify new therapeutic strategies, we modulated MTM1, BIN1 and DNM2 protein levels in the CNM mouse models. We discovered that DNM2 downregulation rescued the XLCNM mouse model and that the overexpression of human BIN1 rescued the XLCNM and the autosomal dominant CNM form due to DNM2 mutations. We have also showed that MTM1 controls cell adhesion and integrin recycling in mammalian skeletal muscle and BIN1 overexpression rescued the integrin recycling alteration in XLCNM mouse model suggesting that MTM1 and BIN1 are functionally linked and necessary for focal adhesions in muscle. Therefore, our studies highlight that MTM1, BIN1 and DNM2 are in a common pathway and, BIN1 and DNM2 could be new therapeutic targets to treat the different CNM forms.