Recognizing, Diagnosing, and Treating

Mitochondrial Diseases: Understanding the

Patient Journey – An Interactive Discussion
Between Patients/Caregivers and HCPs
Presented by:

Michio Hirano, MD Aneesa Licorish

Lucy G. Moses Professor of Neurology Caregiver
Chief, Neuromuscular Medicine Division
Director, H. Houston Merritt Neuromuscular
Research Center
Columbia University Irving Medical Center
Vagelos College of Physicians and Surgeons

Colleen C Muraresku, MS, LCGC Jean Flickinger, PT, MPT, PCS

Senior Genetic Counselor & Program Physical Therapist
Director for the Mitochondrial Medicine Mitochondrial Medicine at the
Frontier Program Children's Hospital of Philadelphia
The Children's Hospital of Philadelphia

This activity is supported by an educational grant from Zogenix.

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Faculty Disclosures

▪ Michio Hirano, MD
− Royalty: Modis Therapeutics following Columbia University policies
− Receipt of lntellectual Property Rights/Patent Holder: Co-inventor of a Columbia University
patent on deoxynucleoside therapy (deoxythymidine and deoxycytidine) for mitochondrial DNA
depletion syndrome. That patent is licensed to Modis Therapeutics (a subsidiary of Zogenix)
− Consulting Fees (e.g., advisory boards): Modis Therapeutics (a subsidiary of Zogenix), Entrada
Therapeutics, and Neurovive.
− Contracted Research: Stealth Therapeutic and Entrada Therapeutics

▪ Colleen C Muraresku, MS, LCGC

− Nothing to disclose

▪ Jean Flickinger, PT, DPT, PCS

− Consulting Fees (e.g., advisory boards): 2020 USMA Pompe Disease Advisory Board

− Fees for Non-CE Services Received Directly from an Ineligible Entity or their Agents (e.g.,
speakers’ bureaus): MDA, Sanofi Genzyme

− Contracted Research: Astellas, IMEL Ttherapeutics and Khondrion,

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Learning Objectives

▪ Identify the key clinical findings and presenting symptoms for

suspicion of mitochondrial diseases, such as Tk2 deficiency

▪ Summarize the disease burden and key clinical

manifestations of mitochondrial diseases across the spectrum
of disease severity and age (i.e., early onset vs late onset)

▪ Utilize genetic testing as part of a diagnostic approach to

differentiate mitochondrial diseases from conditions such as
spinal muscular atrophy and Pompe disease

▪ Explain how treatment with deoxycytidine (dC)/

deoxythymidine (dT) has impacted the lives of
patients/caregivers
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Working Together to Enhance
the Index of Suspicion for Tk2
Deficiency as a Diagnosis for
Progressive Neuropathy
 mtDNA Depletion Syndromes

Suomolainen A, Isohanni P. et al Neuromuscul Disord. 2010;20(7):429-437.

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 Mitochondrial Disease Inheritance
Nuclear-related Mitochondrial Disease
Recurrence Risk
Offspring to Offspring to Affected
Inheritance Pattern Full Siblings
Affected Females Males
Autosomal Recessive
(two pathogenic ALL children will be ALL children will be
25%
variants on opposite carriers** carriers**
chromosomes)
Autosomal Dominant
(one pathogenic 50% if inherited from parent* 50% 50%
variant)
X-linked From mother:
(one pathogenic 50% for sisters & 50% for brothers 50% daughters 100% daughters
variant on the X From father: 50% sons 0% sons
chromosome)*** 100% for sisters & 0% for brothers

* 50% chance to be affected if unaffected parent is a carrier .

**< 1 % if NOT inherited given germline mosaicism.
***X-linked inheritance: Males are typically more affected, and females can be affected due to X-inactivation or asymptomatic. 6
Tk2d: A mtDNA Maintenance Disorder

▪ TK2d leads to mtDNA depletion, multiple deletions,

or both in affected tissues

Tk2 = thymidine kinase 2.

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Image courtesy of the Bioethics Advisory Committee.
Tk2d Function

▪ Mitochondrial deoxyribonucleoside kinase

▪ Phosphorylates pyrimidine deoxynucleosides

Rötig A, Poulton J. Biochim Biophys Acta. 2009;1792(12):1103-1108.

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 Q:
On a scale of 1 to 5, rate your confidence in your
ability to recognize TK2d versus other genetic disease
affecting neuromuscular function.

• 1 (not at all confident)

• 2
• 3
• 4
• 5 (extremely confident)

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Caregiver’s Story

• Early signs/symptoms

• Concerns leading to consultation for a medical opinion

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Vignette – Differential
Diagnosis
Caregiver’s Story

• The journey to seeking a specialist’s opinion

• The differential diagnosis

- SMA? DMD? Other congenital myopathies?

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Clinical Clues to the Diagnosis of Tk2d

▪ Typically, normal at birth and in neonatal period

▪ Subacute progressive weakness in proximal
muscles with early respiratory muscle
involvement
▪ Heart is typically spared (but sinus tachycardia
is common)
▪ Seizures and cognitive impairment are
occasionally present in patients with early
onset disease

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Differential Diagnosis of Tk2d

▪ Mitochondrial disorders including other forms

of mitochondrial depletion syndrome (mtDNA
depletion syndrome), reversible infantile
respiratory chain deficiency, CPEO
▪ Spinal muscular atrophy (SMA)
▪ Congenital myopathies
▪ Muscular dystrophy
▪ Pompe disease (acid maltase deficiency)

CPEO = chronic progressive external ophthalmoplegia

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Early-onset Tk2 Deficiency, Pompe Disease,
and SMA

▪ Present with predominantly proximal or diffuse

limb weakness

▪ Difficulty swallowing

▪ Early respiratory muscle weakness

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Differential Diagnosis of Early-onset Tk2d

Tk2 Deficiency Pompe Disease SMA

Clinical signs Ptosis Ptosis, cardiomegaly, Fasciculations (muscle

enlarged tongue and twitches) of tongue and
liver skeletal muscles

Blood tests Elevated blood creatine Blood creatine kinase Blood CK is normal or
kinase and venous may be normal or mildly elevated
lactate elevated

Electromyography Myopathy Myopathy with Motor neurogenic

increased membrane abnormalities
irritability

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Vignette – Adult
Onset Tk2d
Panel Discussion

• Compare/contrast early/delayed onset and path to

diagnosis

• Tk2d vs Pompe disease

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Late-Onset Tk2d, Pompe Disease, and SMA

▪ Present with predominantly proximal or

diffuse limb weakness

▪ Difficulty swallowing

▪ Early respiratory muscle weakness

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Differential Diagnosis of Late Onset
Tk2d
Tk2d Pompe Disease SMA

Clinical signs Ptosis and Ptosis Fasciculations and

ophthalmoparesis cramps of skeletal
muscles

Blood tests Elevated blood creatine Blood creatine kinase Blood CK is normal or
kinase and venous may be normal or mildly elevated
lactate elevated

Electromyography Myopathy Myopathy with Motor neurogenic

increased membrane abnormalities
irritability (myotonic/
pseudomyotonic
discharges)

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Diagnostic Algorithm

Muraresku CC, et al. Curr Genet Med Rep. 2018;6(2):62-72.

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How to narrow down the differential
diagnosis?
Blood Other types of evaluations
▪ Gamma-glutamyl ▪ Physical therapy assessment
transferase ▪ Electromyography (EMG) – can identify
▪ Lactate and pyruvate nerve dysfunction, muscle dysfunction,
▪ Carnitine or problems with nerve-to-muscle signal
Acylcarnitine transmission
▪ Creatine kinase ▪ Nerve conduction study (NCS) – can
identify nerve damage
Urine ▪ Swallow assessment – can identify risk
▪ Amino acids for aspiration
▪ Organic acids ▪ Pulmonology evaluation – assess for
▪ Urinalysis respiratory issues
▪ Ophthalmology assessment
Tissue-based testing ▪ Hearing evaluation
▪ Cardiology assessment – can identify
cardiomyopathy and prolonged QT
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 Q:
Are muscle biopsies useful in assessing
Tk2d?

A. Yes
B. No
C. I’m not sure

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Tissue-based Analyses

mtDNA RNA mtDNA

Tissue Pathology ETC
sequencing sequencing content
Blood - + + - -

Buccal - + - - -

Urine - + - - -

Fibroblasts - + + + -

Muscle + + + + +

Liver + + - - +

Goldenthal MJ, et al. Mol Genet Metab. 2012;105(3):457-462.

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Tissue-based Analyses
Skeletal Muscle Biopsy
Location is critical: Vastus lateralis,
needed for normative analyses

Morphological analysis
▪ Mitochondrial proliferation
− Ragged red fibers
− Subsarcolemmal accumulation of
mitochondria
▪ COX-deficient fibers

Electron microscopy
▪ Increased number of mitochondria
▪ Structurally abnormal mitochondria
▪ Paracrystalline inclusions

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Roos S, et al. Neuromuscul Disord. 2014;24(8):713-720.
Tissue-based Analyses
Skeletal Muscle Biopsy (cont)
Biochemical testing
▪ Electron transport chain (ETC) activity
− Reported relative to marker enzyme (citrate synthase)
− Isolated defects
− Multiple enzyme defects
▪ Coenzyme Q10 determination
− Primary CoQ10 deficiency is rare
− Secondary CoQ10 deficiency can be seen with mitochondrial
disease; can be used to adjust CoQ10 treatment
▪ mtDNA copy number
− Assesses for mtDNA depletion

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Tissue-based Analyses
Skeletal Muscle Biopsy (cont)
Genetic testing
▪ Mitochondrial DNA sequencing
− Important step even if negative in other tissues; certain
mtDNA variants may be lost over time in blood/buccal
samples
• Examples: mt-tRNA related disease and single large-scale
mtDNA deletions syndromes (SLSMDS)
• mtDNA deletions may be related to underlying condition or
other factors (as older age)
▪ RNA sequencing

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How to Read a Genetic Test Report

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How to Read a Genetic Test Report

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How to Review a mtDNA Depletion Study

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How to Review A Muscle Mitogenome
Analysis Report

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Tk2d: Disease Onset and Progression

Mutant mitochondrial thymidine kinase in

mitochondrial DNA depletion myopathy
Tk2 activity in muscle mitochondria
Sample Substrate
[3H]dTHd [3H]dCyt
Patient 1 3.42±0.38 1.80±0.06
Patient 2 1.03±0.31 0.71±0.59
Patient 4 1.76±0.42 0.68±0.08
Controls 7.55±1.45 5.65±1.89
(5.40-10.51) (4.55-7.59)

▪ Early onset: from birth to 30 months

▪ Progressive weakness of skeletal and respiratory muscles
▪ Elevated CK and lactic acid
▪ Mean age of death: 2.6 years
Saada A, et al. Nat Genet. 2001;29(3):342-344. 32
Lopez-Gomez C, et al. EBioMedicine. 2019;46:356-367.
 Disease Spectrum of 92 Patients with
Tk2d
Infantile-onset myopathy Childhood-onset myopathy Late-onset
39 (42.4%) 37 (40.2%) myopathy
16 (17.4%)
Onset ≤12 months >1-<12 years-old ≥12 years-old
Symptoms Diffuse muscle weakness, Proximal muscle weakness, Muscle weakness
early respiratory failure areflexia
EMG Myogenic +/-neuropathic Myogenic +/-neuopathic Myogenic pattern
pattern pattern
CK ↑↑↑ ↑↑↑ normal-↑↑
mtDNA +++ +++ +/-
depletion
mtDNA _ _ +++
deletions
Other signs/ seizures 7, encephalopathy facial diplegia 11, ptosis 9, ptosis 9, PEO 8,
symptoms 5, cognitive dysfunction 3, PEO 3, hearing loss 2, dysphagia 6,
ptosis 4, facial diplegia 3, cognitive decline 1, respiratory
dysphagia 3, multiple bone encephalopathy 1, prolonged insufficiency 5,
fractures 2, nephropathy 1, QT 1, arrhythmia 1, multiple dysarthria 3,
rigid spine 1, coma episodes bone fractures 1, renal cardiomyopathy 2,
1, cardiomyopathy 1, bi- tubulopathy 1, gynecomastia gynecomastia 1,
ventricular hypertrophy 1, 1 neuropathy 1,
arrhythmia 1, esophageal hearing loss 1
atresia 1

Garone C et al. J Med Genet. 2018;55(8):515-521. 33

 Manifestations Across Tk2d Phenotypes
Early vs Late Onset
Early Onset (≤ 12 years)1 Late Onset (12 Years)2
Symptom Early Onset Symptom Late Onset
Muscle weakness 61/63, 97% Muscle Weakness 8/8
Hypotonia 55/57, 96% Ptosis 7/7
Elevated serum CK 56/59, 95% Dysphagia 5/5
Respiratory difficulties 48/53, 91% Respiratory difficulties 2/4
Loss of previously acquired motor skills 43/49, 88%
mtDNA multiple deletions 4/4
mtDNA depletion 33/40, 83%
Elevated serum CK 2/2
Hyporeflexia 31/39, 79%
Dysphagia 7/18, 39%
Seizures 7/18, 39%
Motor development delay 18/49, 37%
Cognitive Impairment 4/43, 9%

Clear progressive decline →

No reports of remission or spontaneous improvement without
treatment
Key differences: Rate of disease progression, age at death

1. Wang J, et al. J Mol Genet Metab. 2018;124(2):124-130.

2. Dominguez-Gonzalez C, et al. Orphanet J Rare Dis. 2019;14(1):100.
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Vignette – Progression of
Adult Onset Tk2d
Caregiver’s Story and Panel Discussion

• Experiences and concerns about progression

• Progressive nature of Tk2d including differences in

progression between childhood onset and adult-onset

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 Palliative Care, Supportive Care,
and Symptomatic Treatment
Options
• Pulmonary, CNS, Cardiology, and Renal
• GI/Nutrition
• Physical Therapy/Physiotherapy
 Non-invasive
Tracheostomy/
nighttime Cough
Pulmonary ventilatory assists/Chest PT
full-time
ventilation
support

Learning
Seizure Facilitation of
CNS medications
supports for
cognitive delay
motor control

Multisystem Monitoring Bone Cardiac

Monitoring of
Health/Fracture monitoring if
Renal/Liver/Bone liver and kidney
prevention indicated

Failure to Supplemental
nutrition/ G-tube
GI/Nutrition thrive/dietary
dependence
recommendations swallow studies

Garone C, et al. J Med Genet. 2018;55:515–521.

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Physical Therapy Evaluation/Outcome
Measures

Infant onset Childhood Onset Adult onset

• CHOP • Gross Motor • MM-COAST

INTEND Function
• ROM/Tone Measure
assessment • Expanded
Hammersmith
• MM-COAST
(>6 years old)

MM-COAST = Mitochondrial Myopathy-Composite Assessment Tooll ROM = range of motion.

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CHOP INTEND

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 Mitochondrial Myopathy Study –
Objective Findings
▪ Symmetrical weakness
▪ Proximal and distal weakness
− Hip flexors, ankle dorsiflexors, elbow flexors, wrist extensors
• Adults: ankle dorsiflexors
• Children: hip flexors, knee flexors, palmar pinch
▪ Muscle fatigue with repetitions
▪ Poor balance
− Adults: tandem stance more difficult
− Children: eyes closed more difficult
▪ Exercise intolerance: 30s STS and 6MWT (lower total
distance as well as decreasing pace)
▪ Significant dexterity deficits (9-hole peg test and FDT)
Flickinger J, et al. JCSM Clinical Reports. 2021;6(4):109-127. 41
 42
Flickinger J, et al. JCSM Clinical Reports. 2021;6(4):109-127.
Physical Therapy

Evaluations Treatment Supportive

• Early • Developmental • Equipment

identification, treatment, promotion recommendations
early of mobility • Alternative adaptive
intervention, • Orthotic assessment activity
referrals recommendation recommendations
• Outcome • Exercise program
measures to • Home program
monitor recommendations
progress and
detect change

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 Exercise Program

Endurance-based Strength-based
• Endurance exercise: • Strengthening/resistance exercise:
-Sub-maximal, lower load - Higher workload/Intensity
-Longer duration - Shorter duration/low rep
• Some evidence suggests that • Some evidence that strength training
endurance-based training can: can improve strength and is tolerated
- Improve exercise tolerance (decreased and safe.
RPE), peak capacity for work, skeletal • Exercised-induced mitochondrial gene-
muscle ability to use oxygen, quality of shifting in muscle containing satellite
life cells which have low or absent levels of
- Decrease oxidative stress deleted mtDNA
• If exercise is stopped, benefits return to - Eccentric exercise
baseline • Studies are limited by small sample size.

Taivassalo, t, et al. Brain. 2006;129:3391-3401.

Siciliano G, et al. Neuromusc Disord. 2012;22:S172–S177.
Murphy L, et al. Brain (2008), 131, 2832-2840.
Tarnopolsky MA, J Child Neurol. 2014;29(9):1225-1234.
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Orthotics

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Orthotics – Before and After

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Equipment Recommendations

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Caregiver’s Story

▪ What helped

▪ What was most difficult for the caregiver,

child and patient

▪ Decision-making process to address the

evolving needs of the child, including
strategies to work with the care team
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Emerging Therapies for
Tk2 Deficiency
Q:
How would you rate your knowledge of
emerging therapies for Tk2d?

1 (not at all knowledgeable)

2
3
4
5 (extremely knowledgeable)

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Caregiver’s Story and Panel Discussion

▪ Therapies for Tk2d and therapeutic goals

− What matters to patients and caregivers from a clinical
outcome perspective?

▪ Assessment of outcomes in clinical trials and understanding

the patient/caregiver points of view

▪ Clinically meaningful outcomes

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 Deoxynucleoside Therapy in Tk2d

dGuo dGK dGMP dGDP NDK dGTP

dAde dAMP dADP dATP
mtDNA
mt
dThd
ENT1 dThd Tk2 dTMP dTDP NDK dTTP
dCyt dCyt dCMP dCDP dCTP

PNC1 PNC1
PNC2 PNC2
TK1
dThd dTMP dTDP dTTP
DCK
dCyt dCMP dCDP dCTP

Lopez-Gomez C, et al. EBioMedicine. 2019;46:356-367. 52

 Treatment of Tk2d with
Deoxynucleosides/deoxynucleotides
16 Tk2-deficient patients treated under compassionate use protocols
for at least 1 year prior to September 1, 2017.

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Domínguez-González C, et al. Ann Neurol. 2019;86(2):293-303.
 Impact of Tk2 Deficiency on Health and QOL

Domains Rated “Quite a Bit or “Very Much”

How much has Tk2d

changed…

Jensen JP et al. Presented at the World Muscle Society 2021 Virtual Congress, Sept 20-24, 2021.

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Q&A
Live Q&A with the experts

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Conclusions and Panel Discussion

• Goals of Tk2d management

- Early diagnosis
- Improved access to treatment
- Reduced morbidity
- Reduced uncertainty for patients and families who struggle to
understand what they are suffering from and what treatment options
exist

How can caregivers, patients, and clinicians work together to

facilitate earlier recognition of mitochondrial diseases, such as
Tk2d?

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Thank you for
participating today!

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