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clinical implications of basic research
The new engl and j ournal o f medicine
A Reversal of Misfortune for Myotonic Dystrophy?
Thomas A. Cooper, M.D.
Myotonic dystrophy, the most common cause of
adult-onset muscular dystrophy, is a dominantly
inherited disorder in which death is usually caused
by the wasting of skeletal muscle and defects in
cardiac conduction. Mutations in two unrelated
genes cause strikingly similar disease phenotypes.
The more common form, myotonic dystrophy 1,
is caused by an expanded CTG repeat (with ex-
pansions ranging from 50 to 2000 repeats) within
the noncoding 3 untranslated region of the myo-
tonic dystrophy protein kinase (DMPK) gene. The
less common form of the disease, myotonic dys-
trophy 2, is caused by an expanded CCTG repeat
(with expansions ranging from 80 to 11,000 re-
peats) in the first intron of the zinc finger pro-
tein 9 (ZNF9) gene.
1
The disease mechanism remained a mystery
while investigations focused on how dysfunction
of DMPK and ZNF9 might cause disease and how
expansions in noncoding regions of the genes
might disrupt protein expression. The major patho-
genic mechanism is now clear, and it has noth-
ing to do with DMPK and ZNF9 or their expres-
sion. The expanded allele is transcribed into RNA,
which contains unusually long tracts of CUG or
CCUG repeats. These RNA repeats fold into an
unusual hairpin structure, and the contorted, mu-
tant RNAs accumulate in nuclear foci and disrupt
the regulation of alternative splicing of messen-
ger RNA (mRNA).
The majority of human genes undergo alterna-
tive splicing so that pre-mRNAs from individual
genes are processed to produce multiple mRNAs
encoding different but related proteins that usu-
ally have long stretches of sequence in common.
Splicing is often regulated according to cell type
or developmental stage. In myotonic dystrophy,
a subgroup of developmentally regulated splic-
ing events fails to switch from an embryonic to
an adult splicing pattern, resulting in aberrant ex-
pression of embryonic isoforms that are unable
to support the functional requirements of adult
tissues. For example, the characteristic clinical
features of myotonia (muscle hyperexcitability)
and insulin resistance correlate with the reten-
tion of embryonic splicing patterns of the mus-
cle-specific chloride channel (ClC-1) and insulin
receptor, respectively, in skeletal muscle of pa-
tients with myotonic dystrophy.
2
Kanadia et al.
3
have recently described a study
that builds on this knowledge to reverse some
aspects of the disease. Splicing misregulation in
myotonic dystrophy results from altered functions
of two RNA binding proteins CUG-binding pro-
tein 1 (CUG-BP1) and muscleblind-like 1 (MBNL1)
which were identified because they bind CUG
repeats in RNA. CUG-BP1 and MBNL1 are direct
and antagonistic regulators of alternative splic-
ing events that are normally regulated during de-
velopment and misregulated in myotonic dystro-
phy. Several lines of evidence support models in
which increased activity of CUG-BP1 and decreased
activity of MBNL1 induce embryonic pattern
splicing. The fact that MBNL1 colocalizes with nu-
clear RNA foci in the cells of patients with myo-
tonic dystrophy suggests that MBNL1 is seques-
tered by mutant RNAs (Fig. 1).
4
It follows that splicing abnormalities and as-
sociated symptoms due to MBNL sequestration
should be reversed by increased expression of
MBNL. Kanadia et al. tested this hypothesis by in-
ducing the expression of exogenous MBNL1 in
skeletal muscle in a mouse model of myotonic
dystrophy 1 called HSA
LR
. These mice, in which a
human skeletal -actin transgene is expressed
that contains 250 CTG repeats in its 3 untrans-
lated region, have myotonia, histologic abnormal-
ities, and embryonic alternative splicing patterns
that are characteristic of myotonic dystrophy. Ex-
ogenous MBNL1 not only restored ClC-1 and oth-
er splicing abnormalities to the adult patterns but
also reversed the myotonia.
The next step is to address the potential down-
sides of overexpressing a potent splicing regulator.
For example, to avoid the potential for large-scale
misregulated splicing resulting from MBNL1 over-
The New England Journal of Medicine
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Copyright 2006 Massachusetts Medical Society. All rights reserved.
The new engl and j ournal o f medicine
n engl j med 355;17 www.nejm.org october 26, 2006 1826
expression, versions of MBNL1 could be developed
that retain RNA-binding activity but do not have
domains required for splicing activity. A binding
only version could release endogenous MBNL1
from expanded repeat RNA without introducing
additional MBNL1 splicing activity. Alternatively,
a high-throughput screen could be used to identi-
fy small molecules that prevent sequestration of
MBNL1 on CUG or CCUG repeat RNA.
Muscle degeneration is a major clinical feature
of myotonic dystrophy. Kanadia et al. made the
important observation that MBNL1 overexpres-
sion does not reverse histologic abnormalities
in HSA
LR
skeletal muscle. One explanation is that
the level of MBNL1 expression was insufficient
to reverse all aspects of pathogenesis caused by
loss of function of MBNL1. However, it is also
possible that muscle degeneration is due not to
the loss of MBNL1 but rather to altered activities
of other proteins.
2
Addressing this issue may con-
tribute to a full understanding of the pathogenic
mechanism and to the development of a broad
approach for treatment.
The results of the study by Kanadia et al. are
Figure 1. Reversal of Splicing Abnormalities in a Mouse Model of Myotonic Dystrophy.
Myotonic dystrophy is caused by CTG repeats within a noncoding region of the Dmpk gene. It is also caused by the
expansion of a 4-base motif CCTG in a noncoding region of the Znf9 gene (not shown). Transcribed RNA repeats
fold into a hairpin, and the RNA is retained in the nucleus, where it alters the ratio of CUG RNA-binding proteins,
such as CUG-BP1 and MBNL1. These proteins are mutually antagonistic mediators of a subgroup of alternative
splicing events that are disrupted in myotonic dystrophy, in which embryonic forms of some proteins that is,
isoforms typically expressed in the developing embryo and fetus predominate. A recent study by Kanadia et al.
3

showed that increasing the expression of MBNL1 in a mouse model of myotonic dystrophy restored the adult splic-
ing pattern of the ClC-1 protein and reversed the myotonia associated with ClC-1 misregulated splicing.
The New England Journal of Medicine
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Copyright 2006 Massachusetts Medical Society. All rights reserved.
n engl j med 355;17 www.nejm.org october 26, 2006 1827
relevant to other expansion disorders, such as
the fragile X-associated tremorataxia syndrome,
in which a pathogenic mechanism that parallels
that of myotonic dystrophy has been suggested.
2

Overall, these new findings provide additional
support for a primary role of MBNL1 depletion
in the pathogenesis of the disease and represent
a viable therapeutic approach.
No potential conflict of interest relevant to this article was re-
ported.
From the Departments of Pathology and Molecular and Cellular
Biology, Baylor College of Medicine, Houston.
Harper PS. Myotonic dystrophy. 3rd ed. London: W.B. Saun-
ders, 2001.
Ranum LP, Cooper TA. RNA-mediated neuromuscular disor-
ders. Annu Rev Neurosci 2006;29:259-77.
Kanadia RN, Shin J, Yuan Y, et al. Reversal of RNA missplic-
ing and myotonia after muscleblind overexpression in a mouse
poly(CUG) model for myotonic dystrophy. Proc Natl Acad Sci
U S A 2006;103:11748-53.
Lin X, Miller JW, Mankodi A, et al. Failure of MBNL1-depen-
dent postnatal splicing transitions in myotonic dystrophy. Hum
Mol Genet 2006;15:2087-97.
Copyright 2006 Massachusetts Medical Society.
1.
2.
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clinical implications of basic research
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Copyright 2006 Massachusetts Medical Society. All rights reserved.