Missense mutations in small muscle protein X‑linked (SMPX) cause distal myopathy with protein inclusions

Abstract

Using deep phenotyping and high-throughput sequencing, we have identifed a novel type of distal myopathy caused by mutations in the Small muscle protein X-linked (SMPX) gene. Four diferent missense mutations were identifed in ten patients from nine families in fve diferent countries, suggesting that this disease could be prevalent in other populations as well. Haplotype analysis of patients with similar ancestry revealed two diferent founder mutations in Southern Europe and France, indicating that the prevalence in these populations may be higher. In our study all patients presented with highly similar clinical features: adult-onset, usually distal more than proximal limb muscle weakness, slowly progressing over decades with preserved walking. Lower limb muscle imaging showed a characteristic pattern of muscle involvement and fatty degeneration. Histopathological and electron microscopic analysis of patient muscle biopsies revealed myopathic fndings with rimmed vacuoles and the presence of sarcoplasmic inclusions, some with amyloid-like characteristics. In silico predictions and subsequent cell culture studies showed that the missense mutations increase aggregation propensity of the SMPX protein. In cell culture studies, overexpressed SMPX localized to stress granules and slowed down their clearance.