We report an Irish patient with limb-girdle muscular dystrophy 2I (LGMD2I) and cataract. A 28-year-old woman presented with progressive proximal limb weakness since early adolescence. On examination, strength was graded as 3/5 in hip flexors, 4/5 in other muscles of the proximal lower limbs, and 4 1 /5 in shoulder girdle muscles. Distal limb strength was normal. There was mild calf and tongue hypertrophy without scapular winging, contractures, myotonia, or cognitive impairment. A moderately dense cataract was noted in the right eye with 50% reduction in visual acuity. This had been found previously at age 11 years on routine eye examination, but no cause was identified. At presentation, creatine kinase was abnormal at 2,350 U/L. Needle electromyography (EMG) showed short-duration, low-amplitude motor unit potentials in the right vastus lateralis and right biceps brachii muscles. There was no abnormal spontaneous activity. Motor and sensory nerve conduction studies were normal. Echocardiography showed a left ventricular ejection fraction of 40%. Deltoid muscle biopsy showed dystrophic changes. Immunohistochemistry including merosin (laminin-2) was normal. Western blot was not available. Genetic testing for LGMD2I confirmed homozygosity for the 826C>A mutation in the fukutin-related protein (FKRP) gene on chromosome 19q13.3.
DISCUSSIONStructural eye involvement has not been reported in LGMD2I. Mutations in FKRP account for 3 distinct but heterogeneous phenotypes: LGMD2I; congenital muscular dystrophy type 1C (MDC1C); and Walker-Warburg syndrome (WWS). Notably, WWS classically features ophthalmic abnormalities, including cataracts, strabismus, retinal detachment, and microphthalmos.1,2 These conditions comprise a subgroup of muscular dystrophies known as a-dystroglycanopathies.
3FKRP plays a role in glycosylation of a-dystroglycan, an extracellular glycoprotein that mediates deposition of basement membranes by binding to various components such as laminin, perlecan, biglycan, agrin, and neurexin.3,4 Mutations in FKRP result in hypoglycosylation and downregulation of a-dystroglycan and lead to disruption of basement membrane integrity. We hypothesize that the lens capsule, an uninterrupted basement membrane surrounding the ocular lens, became defective in this patient, resulting in capsular opacification and cataract formation. Interestingly, it was demonstrated in an animal model that a reduced FKRP influences the ability of tissue-specific (eye and brain) forms of a-dystroglycan to direct deposition of laminin isoforms to form different basement membranes. 4 Notably, immunohistochemical analysis of muscle tissue from the patient demonstrated normal merosin (laminin-2).LGMD2I is generally believed to affect only muscle, possibly because expression of the FKRP mutation in LGMD2I, compared with that in WWS, results in residual FKRP activity that does not fall below a threshold to produce brain or eye phenotypes.
5Our patient serves as a reminder that merosin may be normal on immunohistochemistry in LGMD2I, although We...