- Charcot-Marie-Tooth disease
Name = Charcot-Marie-Tooth disease
Caption = The foot of a person with Charcot-Marie-Tooth. The lack of muscle, a high arch, and hammer toes are signs of the genetic disease.
DiseasesDB = 5815
ICD10 = ICD10|G|60|0|g|60
ICD9 = ICD9|356.1
MedlinePlus = 000727
eMedicineSubj = orthoped
eMedicineTopic = 43
eMedicine_mult = eMedicine2|pmr|29 | MeshID = D002607
Charcot-Marie-Tooth disease (CMT), known also as Hereditary Motor and Sensory Neuropathy (HMSN), Hereditary Sensorimotor Neuropathy (HSMN), or Peroneal Muscular Atrophy, is a heterogeneous inherited disorder of
nerves ( neuropathy) that is characterized by loss of muscle tissue and touch sensation, predominantly in the feet and legs but also in the hands and arms in the advanced stages of disease. Presently incurable, this disease is one of the most common inherited neurological disorders, with 37 in 100,000 affected.cite journal |author=Krajewski KM, Lewis RA, Fuerst DR, "et al" |title=Neurological dysfunction and axonal degeneration in Charcot-Marie-Tooth disease type 1A |journal=Brain |volume=123 ( Pt 7) |issue= |pages=1516–27 |year=2000 |pmid=10869062 |doi= |url=http://brain.oxfordjournals.org/cgi/content/full/123/7/1516#SEC4]
The disorder is caused by the absence of proteins that are essential for normal function of the nerves due to errors in the genes coding these molecules. The absence of these chemical substances gives rise to dysfunction either in the
axonor the myelinsheath of the nerve cell. Most of the mutations identified result in disrupted myelin production, however a small proportion of mutations occur in gene MFN2, which doesn't seem to have anything to do with myelin. Instead MFN2controls behaviour of mitochondria. Recent research showed that the mutated MFN2causes mitochondria to form large clusters. In nerve cells these large clusters of mitochondria failed to travel down the axon towards the synapses. It is suggested these mitochondria clots make the synapses fail, resulting in CMT disease.cite journal |author=Baloh RH, Schmidt RE, Pestronk A, Milbrandt J |title=Altered axonal mitochondrial transport in the pathogenesis of Charcot-Marie-Tooth disease from mitofusin 2 mutations |journal=J. Neurosci. |volume=27 |issue=2 |pages=422–30 |year=2007 |pmid=17215403 |doi=10.1523/JNEUROSCI.4798-06.2007 |url=http://www.jneurosci.org/cgi/content/abstract/27/2/422]
The different classes of this disorder have been divided into the primary demyelinating neuropathies (CMT1, CMT3, and CMT4) and the primary axonal neuropathies (CMT2). Recent studies, however, show that the pathologies of these two classes are frequently intermingled, due to the dependence and close cellular interaction of
Schwann cells and neurons. Schwann cells are responsible for myelin formation, enwrapping neural axons with their plasma membranes in a process called “myelination”.cite journal |author=Berger P, Young P, Suter U |title=Molecular cell biology of Charcot-Marie-Tooth disease |journal=Neurogenetics |volume=4 |issue=1 |pages=1–15 |year=2002 |pmid=12030326 |doi= |url=http://link.springer.de/link/service/journals/10048/bibs/2004001/20040001.htm]
The molecular structure of the nerve depends upon the interactions between neurons, Schwann cells, and
fibroblasts. Schwann cells and neurons, in particular, exchange signals that regulate survival and differentiation during development. These signals are important to CMT disease because a disturbed communication between Schwann cells and neurons, resulting from a genetic defect, is observed in this disorder.
It is clear that interaction with demyelinating Schwann cells causes the expression of abnormal axonal structure and function, but we still do not know how these abnormalities result in CMT. One possibility is that the weakness and sensory loss experienced by patients with CMT is a result of axonal degradation. Another possibility is that axonal dysfunction occurs, not degeneration, and that this dysfunction is induced by demyelinating Schwann cells.]
Most patients experience demyelinating neuropathies, and this is characterized by a reduction in nerve conduction velocity (NCV), due to a partial or complete loss of the myelin sheath. Axonopathies, on the other hand, are characterized by a reduced compound muscle action potential (CMAP), while NCV is normal or only slightly reduced.
The disease is named for those who classically described it:
Jean-Martin Charcot(1825-1893) and his pupil Pierre Marie(1853-1940) ("Sur une forme particulière d'atrophie musculaire progressive, souvent familiale débutant par les pieds et les jambes et atteignant plus tard les mains", Revue médicale, Paris, 1886; 6: 97-138.), and Howard Henry Tooth(1856-1925) ("The peroneal type of progressive muscular atrophy", dissertation, London, 1886.)
Symptoms usually begin in late childhood or early adulthood. Usually, the initial symptom is
foot dropearly in the course of the disease. This can also cause hammer toe, where the toes are always curled. Wasting of muscle tissue of the lower parts of the legs may give rise to "stork leg" or "inverted bottle" appearance. Weakness in the hands and forearms occurs in many people later in life as the disease progresses.
Symptoms and progression of the disease can vary. Breathing can be affected in some; so can hearing, vision, and the neck and shoulder muscles.
Scoliosisis common. Hip sockets can be malformed. Gastrointestinal problems can be part of CMT, as can chewing, swallowing, and speaking (as vocal cordsatrophy). A tremorcan develop as muscles waste. Pregnancyhas been known to exacerbate CMT, as well as extreme emotional stress.
A definitive diagnosis for a specific type of CMT is established via genetic testing for most types. However, some
genetic markers have not yet been identified, and a diagnosis can also be established via an electromyographyexamination (which shows that the velocity of nerve impulse conduction is decreased and the time required to charge the nerve is increased) and nerve biopsy.
Types of the disease
* CMT Type 1 (CMT1): Type 1 affects approximately 80% of CMT patients and is the most common type of CMT. The subtypes share clinical symptoms.
Autosomal dominant. Causes demyelination, which can be detected by measuring nerve conduction velocities.
* CMT Type 2 (CMT2): Type 2 affects approximately 20-40% of CMT patients. Type 2 CMT is
Autosomal dominantneuropathy with its main effect on the axon. The average nerve conduction velocityis slightly below normal, but generally above 38m/s
* CMT Type 3 (CMT3): Type 3 affects very few CMT patients.
* CMT Type 4 (CMT4): Type 4 affects very few CMT patients.
* CMT X-Linked (
CMTX): CMTX affects approximately 10-20% of CMT patients and is X-linked dominant. Approx 10% of X-linked CMT patients have some other form than CMTX. However a study published in 1997 indicates that a connexin 32 gene mutation is associated with this form which may be more common than previously thought. [cite journal |author=Latour P, Fabreguette A, Ressot C, "et al" |title=New mutations in the X-linked form of Charcot-Marie-Tooth disease |journal=Eur. Neurol. |volume=37 |issue=1 |pages=38–42 |year=1997 |pmid=9018031 |doi= |url=]
More details on the types are provided in the table below:
Genetic testing is available for many of the different types of Charcot-Marie-Tooth. For a listing of test availabilities, see [http://www.genetests.org GeneTests.org]
Although there is no current standard treatment, the use of
ascorbic acidhas been proposed, and has shown some benefit in animal models.cite journal |author=Passage E, Norreel JC, Noack-Fraissignes P, "et al" |title=Ascorbic acid treatment corrects the phenotype of a mouse model of Charcot-Marie-Tooth disease |journal=Nat. Med. |volume=10 |issue=4 |pages=396–401 |year=2004 |pmid=15034573 |doi=10.1038/nm1023] There is currently a clinical trial to determine the effectiveness of high doses of ascorbic acid (vitamin C) in treating humans with CMT type 1A. [cite web |url=http://www.mda.org/research/view_ctrial.aspx?id=186 |title=Clinical Trials - Neuromuscular Trial/Study |date=2007-07-18 |accessdate=2008-05-28] Not all types of CMT are expected to respond to this treatment.
The Charcot-Marie-Tooth Association classifies the
chemotherapydrug vincristineas a "definite high risk" and states that "vincristine has been proven hazardous and should be avoided by all CMT patients, including those with no symptoms." [ [http://www.charcot-marie-tooth.org/med_alert.php CMT Association: Medical Alert] ]
There are also several corrective surgical procedures that can be done to improve physical condition.
* [http://www.charcot-marie-tooth.org/ Charcot Marie Tooth Association]
* [http://www.med.wayne.edu/neurology/clin_programs/labs/cmt/CMTDatabase.htm Charcot Marie Tooth North American Database] - patients with CMT who do not live in North America are also encouraged to join
* [http://www.mdausa.org/ Muscular Dystrophy Association] - Although CMT is not a form of Muscular Dystrophy, it is one of several non-muscular dystrophy diseases for which the MDA offers support
* [http://www.muscle.ca/ Muscular Dystrophy Canada]
* [http://www.hnf-cure.org/ Hereditary Neuropathy Foundation]
* [http://www.cmt.org.uk/ CMT International]
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