Gene Reports 11 (2018) 34–41

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Gene Reports
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Molecular and clinical spectrum of type 1 myotonic dystrophy T

a, a b
Ashok Kumar , Sarita Agarwal , Sunil Pradhan
a Department of Genetics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India
b Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India

ARTICLE INFO ABSTRACT

Keywords: Myotonic dystrophy type 1 is a chronic, slowly progressing, inherited multisystemic autosomal-dominant dis-ease, caused by
Type 1 myotonic dystrophy expansion of CTG repeats in DMPK gene. The aim of present study was to analyze the molecular expansion in DM1 families
Dystrophia myotonica protein kinase (DMPK) and in normal individuals and to establish its relationships with disease. Clinically suspected 30 subjects (from 29 families) of
Triplet primed PCR (TP-PCR) DM1, 75 family members and 400 normal individuals were included in the study. Molecular diagnosis of CTG repeat
Muscular Dystrophy Rating Scale (MDRS)
expansion was performed by Myotonic Dystrophy Short PCR (MDSP) and Triplet primed-PCR (TP-PCR) and followed
Genotype-phenotype correlation
fragment analysis on ABI-310 Genetic Analyzer. SPSS version 16 and Pearson correlation coefficient were used for statistical
analysis. All 30 patients had CTG repeat expansion pattern, correlated well with clinical phenotypes of DM1. Among 75, nine
family members were permutated, while sixty six were normal. The allele frequency to repeat no. 5, 9–13 constituted
approximate 80% of all 15 distributed allele (3–29) in normal individuals of DM1 families. Among, 400 normal individuals,
the allele frequency to repeat number 5, 9–12, and 14–15 constituted approximate 85% out of 23 distributed allele (3–29).
The expanded CTG repeat significantly correlated with age at onset, myotonia, wasting, weakness, hypersomnia, abnormal
nerve conduction, clinical score and muscular disability rating scale. MDSP and TP-PCR could be successfully used for the
identification of repeat expansion in normal individuals and in DM1 families. The finding is helpful not only for laboratory
physicians performing tests and making molecular diagnosis, but also for clinicians diagnosing and counselling patients with
variable onset and systemic involvement.

1. Introduction
Myotonic dystrophy type 1 (DM1; OMIM 160900) is the most common
form of inherited autosomal dominant adult muscular dys-trophy. DM1 is
characterized by myotonia with weakness and wasting of distal muscles,
cataracts, cardiac arrhythmias, hypogonadism, frontal balding, and mental
impairment (Harper, 2001). The causative muta-tion in DM1 is an expansion
of an unstable tandem repeat of the CTG sequence located in the 3′
untranslated region (UTR) of the myotonin protein kinase gene (DMPK),
which is located on chromosome 19q13.3 (Mahadevan et al., 1992; Brook et
al., 1992; Buxton et al., 1992). The CTG repeat number varies from 3 to 34 in
healthy individuals, whereas in DM1 patients, the number varies from 50 to
several thousand (IMDC, 2000; Kumar et al., 2013). The disorder shows
genetic anticipation with expansion of the repeat number dependent on the
sex of the transmit-ting parent. Offspring of an individual with an expanded
allele have a 50% chance of inheriting the mutant allele. DM1 has an
incidence of 1 in 8000 in the Western European and North American
populations (Harper, 1989) and a lower incidence of 1 in 20,000 in Japan
(Davies et al., 1992). DM1 prevalence in the western Sweden thus seems to
be
somewhat higher than elsewhere in Europe (Lindberg and Bjerkne, 2017).
However, prevalence of the disease in diverse Indian popula-tions is still
unknown.
On the basis of clinical symptoms, severity and age-of onset of disease
myotonic dystrophy patients are often divided into congenital, mild and
juvenile groups. The most severe form is congenital myotonic dystrophy
(CDM) which is associated with generalized muscular hy-potonia, talipes and
mental retardation while mildest form (seen in middle-to-old age) is
characterized by cataracts, baldness and minimal on absent muscle
involvement and juvenile/adult form is phenotypi-cally variable with
myotonia, muscle weakness, cardiac arrhythmias, male balding,
hypogonadism and glucose intolerance etc.
Diagnosis of DM1, that shares similar clinical symptoms with spi-
nocerebellar ataxia and Friedreich ataxia, in clinical setup is difficult.
Molecular method for the detection of normal and expanded alleles of
myotonic dystrophy are PCR-RFLP (Restriction fragment length poly-
morphism) (Shaw et al., 1985), Nested and fluorescent PCR (Sermon et al.,
1997; Sermon et al., 1998), multiplex PCR and Southern blotting (Sermon et
al., 2001; Goossens et al., 2008; Spits et al., 2006) and Triplet Primed-PCR
(TP-PCR) (Warner et al., 1996) and a choice

Corresponding author at: Department of Genetics, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow 226014, India. E-mail
addresses: chemistry.ashok83@gmail.com (A. Kumar), saritasgpgi@gmail.com (S. Agarwal), spradhan@sgpgi.ac.in (S. Pradhan).

https://doi.org/10.1016/j.genrep.2018.01.006
Received 31 July 2017; Received in revised form 18 January 2018; Accepted 24 January 2018
Available online 03 February 2018
2452-0144/ © 2018 Published by Elsevier Inc.
A. Kumar et al. Gene Reports 11 (2018) 34–41

methodology has been implemented for the screening of expanded al-lele in Mild cardiac symptoms 4
the DMPK gene. Clinically myotonic dystrophy is diagnosed by the elevated Severe cardiac symptoms 6
level of muscle enzyme SCK (Serum creatinine kinase), characteristics 6 Mild dysphasia 2
pattern of electromyography (EMG) peaks, nerve con-duction velocity Nasal regurgitation 4
(NCV), muscle biopsy, and various other parameters, but the variable clinical Tube feeding 6
features of DM1 make molecular tests im-portant for accurate diagnosis. 7 Minimal help for activities of daily living 2
Dependent 4
Therefore, the aim of the present study was to analyze the molecular and Chair bound 6
clinical characteristics of DM1 patients and to establish possible relationships 8 Recurrent cough 2
between the molecular aberrations and disease pheno-types in Indians. Recurrent aspiration 4
Bronchiectasis 6
9 Mild testicular atrophy 2
2. Materials and methods Testicular atrophy with impotence 4
Severe testicular atrophy with no children 6
2.1. Clinical assessment 10 Normal CK level (25–192 U/l) 0
192–500 units 1
- This study was approved by the Institutional Ethics Committee. 501–1000 2
- DM1 patients were diagnosed from January 2011 to March 2017. more than 1000 3
11 Abnormal nerve conduction 1
- Total 30 DM1 patients and 75 related individuals from 29 families
12 Distal myopathic EMG 1
were referred to our hospital and also 400 normal individual from
Proximal and distal muscles EMG 2
Indian population (Northern India and North-east India) were screened
13 MDRS grading
for CTG repeat diagnosis.
Grade 1 - represent no clinical muscular impairment
- Patients having complaint of muscle wasting, jaw and temporal Grade 2 - minimal signs of weakness
wasting, impairment in gripping capacity, arrhythmia, facial weakness Grade 3 - distal weakness
and hypersomnia included in the study while patients having any other Grade 4 - mild or moderate proximal weakness
neurological disorder or any other severe or familiar disease excluded Grade 5 - severe proximal weakness
from the study.
- Clinically, DM1 patients diagnosed on the basis of detailed history of
disease, age of onset, physical examination, biochemical testing and 2.3. Molecular genetic analysis
electrophysiological testing like NCV (nerve conduction velocity), and
EMG (electromyography) and by several other parameters. 2.3.1. DNA extraction
- Age and clinical description of each patient were reported in this study Informed consent was obtained from each subject and then pro-cessed for
as those at the time of blood sampling. DNA isolation by standard phenol chloroform method. The quality and purity
of DNA was checked by measuring optical density (OD) at 260 nm and 280
nm. The ratio of absorbance at 260 and 280 nm of DNA was around 1.7–1.9.
2.2. Grading of clinical severity The quality and purity was confirmed by 0.8% agarose gel electrophoresis in
1× TBE buffer and stored at −20 °C till further use.
A scoring system (Table A) was used to evaluate the severity of the salient
clinical features. Scoring scale has provided 0 (minimum)–70 (maximum)
points (Devi et al., 1998). The value 70 (Table 1) represents severe illness. In
Indian scenario, clinical score ranging from 8 to 39 suggesting a mild to 2.3.2. PCR and CTG repeat expansion analysis
moderate severity of the disease. MDRS measure the degree of muscle The CTG repeat region in the DMPK gene was amplified by Myotonic
impairment. MDRS is based on a five-point scale (Mathieu et al., 1992). Dystrophy Short PCR (MDSP) to determine the sizes of normal and/or
permutated trinucleotide repeats. PCR was performed in a reaction volume of
Table A 25 μl using 50 ng genomic DNA with 5 pmol of each primers 101-F (5′-FAM-
Scoring scale for severity of disease. CTT CCC AGG CCT GCA GTT TGC CCA TC-3′) and 102-R (5′-GAA CGG
GGC TCG AAG GGT CCT TGT AGC-3′) (Brook et al., 1992). The cycling
Scoring and grading of severity of disease profiles were as follows: 5 min at 95 °C, 34 cycles of 10 s at 95 °C, 30 s at 62
°C, and 30 s at 72 °C. A final ex-tension at 72 °C for 10 min completed the
S.N. Parameters Score reaction. Repeat size was calculated by subtracting the number of base pairs
of the flanking re-gion from the total length of the PCR products and dividing
1 Myotonia in eyelids 2
the result by three. The fragment was analysed by ABI PRISM 310 Genetic
Masseter-temporalis tongue 1
Ana-lyzer with the Gene Mapper ID 3.1 software (Applied Biosystems,
Proximal and distal muscles of upper and lower limb 4
Foster City, CA, USA).
Total score 7
2 Wasting in muscles of face 1 To determine the expanded CTG repeat allele expansion, Triplet Repeat
Neck 1 PCR (TP-PCR) was carried out in a reaction volume of 25 μl using 50 ng
Proximal, distal muscles of upper and lower limbs 4 genomic DNA with 10 pmol of primer P1-F (5′-FAM-AGA AAG AAA TGG
Total score 6 TTC TGT GAT CCC-3′), 8 pmol of primer P3-R (5′-TAC GCA TCC CAG
3 Mild or moderate proximal weakness 1 TTT GAG ACG-3′), and 2 pmol of primer P4CTG (5′-TAC GCA TCC GAG
Minimal signs of weakness 2 TTT GAG ACG TGC TGC TGC TGC TGC T-3′) (Warner et al., 1996). The
Distal weakness 2 reaction conditions were as: 10 min at 96 °C, 30 cycles of 1 min at 94 °C, 1
No clinical muscular impairment 3 min at 60 °C, 2 min at 72 °C, followed by final ex-tension at 72 °C for 10
Severe proximal weakness 5 min. The fragment was done by ABI PRISM 310 Genetic Analyzer.
4 Abnormal glucose 1
Abnormal glucose with diabetes 2
Diabetic complication 3
5 Abnormal ECG and Echo without cardiac symptoms 2
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A. Kumar et al. Gene Reports 11 (2018) 34–41

Table 1
Clinical features and Severity scale and scores in 30 DM1 patients.

Patient/sex Age at onset (y) Age at sampling (y) Dur (y) FH MT WS WK DM CD D ADL Asp T CK NC EMG Score MDRS
7 6 15 3 6 6 6 6 6 6 1 2 70

1/M 28 30 2 N 3 4 8 – – – 2 – – – 1 1 19 2
2/M 23 29 6 N 3 5 12 – – – – – – 1 1 2 24 3
3/F 43 45 2 N 4 4 6 – – – – 2 4 – 1 1 22 3
4/M 27 31 4 N 4 6 7 – – – 2 – – – 1 1 21 2
5/M 25 30 5 N 4 4 6 – – – – – – – 1 – 15 2
6/M 20 23 3 N 4 4 8 – – – – – – 1 1 1 19 2
7/M 13 17 4 N 4 5 8 – – – 2 – – 1 1 2 23 4
8/M 36 40 4 N 2 4 1 1 – – 2 – – – – 1 11 1
9/F 30 37 7 N 2 2 4 – – – 2 – 6 1 1 1 19 2
10/M 39 40 1 N 3 2 4 – – – 2 – – 3 – 1 15 2
11/M 10 25 15 N 4 5 6 – – – 4 – – 1 1 1 22 3
12/M 29 34 5 N 4 4 7 2 – – 2 4 – 1 1 1 26 3
13/M 34 36 2 N 7 6 8 – – – 6 – 6 3 1 2 39 5
14/M 9 20 11 Y 4 5 6 – 4 – 4 2 – 1 1 2 29 3
14m/F 37 42 5 N 4 4 8 2 4 – 2 2 4 1 1 2 34 3
15/F 40 43 3 N 2 2 1 1 2 4 – – – – – 1 13 1
16/M 10 25 15 N 2 4 4 – – 2 2 – – – 1 2 17 2
17/M 5 27 22 N 2 2 3 – – – 2 – – – 1 2 12 2
18/M 17 35 18 N 4 5 7 – – 2 4 2 4 1 1 1 31 2
19/M 49 52 3 N 2 4 1 – 2 2 2 2 – 3 1 1 20 1
20/F 39 40 1 N 4 4 6 – – – – – 4 1 1 1 21 2
21/M 22 27 5 N 6 6 12 – – – 4 – – 1 1 2 32 5
22/M 16 29 13 N 6 6 8 – – – – – – 1 1 2 24 2
23/M 26 31 5 N 2 2 4 1 – 2 – – – 1 1 1 14 2
24/F 7 9 2 N 3 2 4 – – – 6 – – 2 1 2 20 4
25/M 47 57 10 N 3 5 7 – – 2 2 – – – 1 2 22 2
26/F 32 34 2 N 4 4 12 – 2 – 2 – 4 1 1 1 31 3
27/M 40 42 2 N 4 5 8 – – 2 – 2 2 1 1 2 27 3
28/M 21 25 4 N 2 2 4 – – – 2 – – 1 – 1 12 2
29/F 20 23 3 N 4 4 5 – – – 2 – – 1 1 2 19 2

14m, mother of patient no. 14; Dur, duration of the disease; MT, myotonia; WS, wasting; WK, weakness; DM, diabetes mellitus; CD, cardiac involvement; D, dysphasia; ADL, activities of daily
living; Asp., aspiration; T, testicular atrophy; CK, creatinine kinase; NC, nerve conduction; EMG; electromyography; MDRS, muscular disability rating scale. The maximum score of all parameters
were shown.

2.3.3. Assessment of repeat expansion
CTG repeat expansion performed in all individuals (n = 105) belong from
29 DM1 family as well as in all 400 control. Nine DM1 families (family 2, 5,
7, 8, 10, 16, 17, 21, 25) were selected for complete family screening for
molecular diagnosis of CTG repeat expansion.
2.4. Genotype-phenotype analysis
The relationships between CTG repeat expansions and the level of serum
CK, the age of onset, and various clinical and biochemical parameters were
analysed by Pearson's correlation coefficient test.
living, 4 patients were dependent for daily activities and 2 were wheel-chair
bound and required assistance for most of daily activities (Table 1).
Investigations revealed normal CK (below 192 U/l) in 9 patients, over 192
U/l in 17 patients, over 500 U/l in 1 patient, and over 1000 U/ l in 3 patients.
Nerve conduction was abnormal in 27 patients (90%) and myopathic EMG
limited to distal muscles in 16 patients (53.3%) and to proximal muscle in
addition to distal muscle in 13 patients (43.3%). The clinical score or severity
of sum score (SSS) ranged from 11 to 39, with 14 patients having a score
between 11 and 20, 11 be-tween 21 and 30, and 5 between 31 and 39 (Table
1).

2.5. Statistical analysis 3.1. Molecular genetic analysis

The CTG repeat expansion for each patient was expressed as median and
range. In each test, a p value of less than 0.05 was considered statistically
significant. Analysis was performed using SPSS for Windows version 16.0.
3. Results
During the period of more than four year (Jan. 2011 to March 2017),
blood samples (n = 105) from 29 DM1 families had been col-lected at
SGPGIMS, and among them 30 had pathogenic DM1 ac-counting for 28.57%
of total individual. The mean age at onset of symptoms was 26.47 ± 12.33
(range 5–49 year), mean age of pre-sentation (age at sampling) was 32.6 ±
10.2 (range 9–57 year) and the mean duration of illness was 6.13 ± 5.40
(range 1–22 year). All pa-tients had grip myotonia and distal muscles of upper
limbs were weak and atrophic in more than 75% of the patient. The 9 patient
were functionally independent, 15 patients required minimal help for daily
A total of 30 patients and 75 related individuals from 29 DM1 fa-milies,
were recruited in the present study for molecular diagnosis of the disease by
MDSP and TP-PCR methodology (Brook et al., 1992; Warner et al., 1996)
(Figs. 1 & 2). The age at presentation, CTG repeats and their expansions, and
the disease status had been shown in pedi-grees (Figs. S1 & S2, Table S1).
MDSP amplify normal and permutated allele but it does not amplify
pathogenic expanded CTG repeat (Fig. 1). The TP-PCR give character-istics
peak pattern for normal, permutated and expanded CTG repeat allele (Fig. 2).
Among 75, all members of DM1 families, except 10, were heterozygous for
CTG repeat size (86.67%) and nine were permutated (12%), and remaining
family members (n = 66) were normal (88%) for molecular status of CTG
repeat. Complete family screening for CTG repeat had been done in nine
families (families 2, 5, 7, 8, 10, 16, 17, 21,
25) while parents of proband 6 (P6) were died before the diagnosis of the
disease (Figs. S1 & S2, Table S1).

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A. Kumar et al.
Fig. 1. Myotonic Dystrophy Short-PCR (MDSP) product Gene scan analysis of (a) electrophorogram of a normal individual of a DM1 family member (b) a permutated DM1 individual
electrophorogram (c) pics of a DM1 patient. Horizontal scale indicates size in base pairs while fluorescent intensity of the normal and/or normal/permutated alleles represented by vertical scale.
3.2. Clinical and laboratory findings and genotype-phenotype correlation
Myotonia, wasting and muscular weakness were present in all pa-tients.
Other clinical manifestations were found less frequently (Table 1). The
correlation was assessed between the presence or ab-sence of each symptom
and CTG expansion. The age of onset was in-versely significant correlated
with the CTG repeat expansion (r = −0.021, p = 0.027) (Table 2). In contrast,
CTG expansion were positively significant correlated with myotonia (r =
0.750, p = 0.0002), wasting (r = 0.778, p = 0.00038), weakness (r = 0.779, p =
0.0006), hypersomnia (r = 0.370, p = 0.042), abnormal nerve conduction (r =
0.555, p = 0.001), SSS or clinical score (r = 0.673, p = 0.0006), MDRS (r =
0.428, p = 0.018) (Table 2). The level of serum CK was abnormal in 21
patients (70.0%), but no relationship was observed between the CK level and
the CTG repeat expansion (r = 0.301, p = 0.106). Similarly, the parameters
like SLD (speech and languages disability), LWD (learning and writing
disability), ADL
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Gene Reports 11 (2018) 34–41
(activity of daily living), CKMB (creatine kinase-MB) CKMM (creatine
kinase muscle isoform) showed no significantly correlation with CTG
expansion also (Table 2).
3.3. Allele distribution in normal individuals and normal members of 29
DM1 families
The 400 normal Indian (group 1) subjects and 66 normal members (group
2) from 29 DM1 families were analysed for repeat length var-iation at the
DM1 locus using Gene scan. Group 1st population had a mean repeat size of
4.0 ± 6.7. The allele corresponding to repeat number 5, 9–12, 14–15
constitute approximate 85% out of 23 dis-tributed allele (range 3–29) and 5
repeats being the most common followed by 11 repeats accounting for 26.28
and 20.36% of the popu-lation respectively. The % frequency of allele greater
than 19 CTG re-peat was 5.87%. Similarly, group 2nd population had a mean
repeat size of 4.0 ± 7.3. The allele corresponding to repeat no. 5, 9–13
A. Kumar et al. Gene Reports 11 (2018) 34–41

Fig. 2. TP-PCR product Gene scan analysis of (a) electrophorogram of a normal individual of a DM1 family member (b) a premutated DM1 individual electrophorogram (c) pics of a DM1 patient.
Horizontal and vertical scales indicate size in base pairs and fluorescent intensity of the expanded alleles respectively.

constituted approximate 80% of all 15 distributed allele (range 3–29). Again 5
repeats being the most common followed by 9, 10, 11 repeats accounting for
26.52, 18.93, 7.58%, 21.21% of the population respec-tively, and the
frequency of allele greater than 19 repeats was about 2% (Fig. 3).
4. Discussion
The discovery that a number of neurological disorders are caused by the
expansion of triplet repeats has led to new understanding of the disease
process (Howeler et al., 1989; Timchenko and Caskey, 1996). Beginning with
Fragile X syndrome and myotonic dystrophy the list of such diseases has
grown to include Huntington's disease, Kennedy's disease, Dentato Rubro
Pallido Luysian atrophy (DRPLA), spinocer-ebellar ataxia (SCA) 1–3, 6–7
and Freidrich's ataxia etc. (Timchenko
and Caskey, 1996; Mandel, 1997). It is quite possible that more disease will
be added to this list.
The MDSP-TPPCR method used in this study provides a convenient tool
for the molecular diagnosis of DM1. Molecular genetic analysis for CTG
repeat expansion were performed in 29 families of DM1, constitute total 105
individuals (30 patients and 75 family members). The ex-pansions were
detected in all 30 patients while among 75 family members, except nine
(permutated), 66 (group 2) were normal. Additionally, 400 normal individuals
(group 1) were subjected to mo-lecular diagnosis of CTG repeat. Normal
alleles were distributed with the highest peak at 3, and followed by 11 in both
group 1st and 2nd, yet the percentage allele frequencies corresponding to
these CTG repeats were different.
In the present study, the clinical features of 30 patients with DM1 have
been analysed. The disease features were similar to the earlier

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A. Kumar et al. Gene Reports 11 (2018) 34–41

Table 2 which had a frequency of 21 and 7.4% respectively. Alleles of greater than 18
DM1: correlation coefficient of severity of disease. repeats were only 1.4% in Taiwanese with low prevalence of DM1 (Pan et al.,
2001) and 4.2% in Koreans (Kim et al., 2008). The African population which
Variables Repeat Variables Repeat expansion
expansion r (p-value) shows no alleles greater than 19 has a low incidence of DM1. As yet, there are
r (p-value) very few reports from India of molecular diagnosis in myotonic dystrophy.
The studies from NIM-HANS (Bangalore, South India) (Devi et al., 1998),
Age at onset −0.021 (0.027) Hypersomnia 0.370 (0.042)
and Saha Institute of Nuclear Physics, Calcutta (East India) (Basu et al., 2000)
Duration of disease 0.062 (0.746) ADL −0.154 (0.4160)
Myotonia 0.750 (0.0002) Aspiration 0.223 (0.2360) reported that the frequency of CTG repeat greater than 19 was very low. In
Wasting 0.778 (0.00038) Testicular atrophy 0.267 (0.155) our present study, group 1st and group 2nd show a frequencies of such alleles
Weakness 0.779 (0.0006) CK 0.301 (0.1060) approximately 5.87 and 2% respectively. Our study from SGPGIMS,
Diabetes 0.253 (0.177) CKMB −0.222 (0.238) Lucknow (Northern India) had same concordance with the above findings.
Cardiac involvement 0.063 (0.740) CKMM −0.009 (0.963)
Dysphasia 0.279 (0.136) Nerve conduction 0.555 (0.001)
This could explain the relatively low incidences of the disease in our
Dyspepsia 0.098 (0.607) Clinical score 0.673 (0.00017) population as the tool of such alleles, from which ex-pansions are thought to
LWD 0.189 (0.317) MDRS 0.428 (0.018) occur, are less frequent.
SLD 0.283 (0.130)
Genotype-phenotype relationship in DM1 had been widely studied in
LWD, learning and writing disability; SLD, speech and languages disability; CKMB, creatine
many ethnicities, but few researches have been conducted in Indian patients
kinase-MB; CKMM, creatine kinase muscle isoform.
(Devi et al., 1998; Basu et al., 2000). In the previous studies, CTG expansion
was known to be correlated with diverse phenotypic findings such as age at
reports for the Caucasian population (Harper, 1989). A clinical score was
onset (Devi et al., 1998), muscle disability (Jaspert et al., 1995), heart
developed to assess the severity with arrange of Zero to a maximal disease
involvement (Melacini et al., 1995; Tokgozoglu et al., 1995), intelligence
severity of seventy. It is noteworthy that the clinical score ranging from 11 to
quotient, phosphate excretion and thyrotropin-releasing hormone, impaired
39 suggesting a mild to moderate severity of the disease in the Indian
glucose metabolism, go-nadal dysfunction (Mastrogiacomo et al., 1994), and
population.
reduced im-munoglobulin levels (Harper, 2001). However, symptoms such as
Earlier studied have tried to correlate the incidence of disease with the
cat-aract, myotonia and gastrointestinal dysfunction were not correlated with
presence of alleles greater than 19 repeats in the normal population (Devi et
the trinucleotide repeat expansion (Jaspert et al., 1995). The re-peat expansion
al., 1998, Basu et al., 2000; Deka et al., 1996; Imbert et al., 1993). The
correlated significantly with the clinical status (clinical score and MDRS)
frequency of alleles with more than 19 CTG repeats differs according to
(Gennarelli et al., 1996), however, other group found no correlation between
ethnicity. The most frequent allele was different between Caucasians and
repeat expansion and the clinical severity score (Devi et al., 1998). In this
Asians: five repeats is the most common in European, and 12 repeats in
study, various phenotypic characteristics of Indian patients were reviewed in
Japanese and Koreans each (Deka et al., 1996; Martorell et al., 2001; Choi et
relation to genotype, but only the eight findings, age of onset, myotonia,
al., 1999). These studies suggest that larger alleles provide a pool from which
wasting, the presence of mus-cular weakness, hypersomnia, abnormal nerve
expansion to large unstable repeat sizes could occur. According to this
conduction, SSS or clinical score, and MDRS were related to the repeat
hypothesis the highest in-cidence of the disease which is seen in Western
expansions. Age of
Europeans followed by the Japanese could be correlated with alleles greater
than 19 repeats

Fig. 3. Distribution of alleles at the DM1 locus in the normal individuals (n = 400) of Indian population and normal individual of DM1 family members (n = 65).

39
A. Kumar et al.
onset negatively significant correlated with CTG repeat expansion, this
confirms the phenomenon of anticipation. However, other seven phe-notype
positively significant correlated. Our findings have same con-cordance with
several previous reports (Harper, 2001; Devi et al., 1998; Jaspert et al., 1995;
Gennarelli et al., 1996). These eight phenotypic expressions may be used with
caution as representative clinical features implying severe molecular defect in
Indian patients, until more in-formation becomes available. The possibility of
other genotype-phe-notype relationships in clinical manifestations should be
elucidated through further studies.
5. Conclusion
Overall, the current molecular genetic test confirmed the molecular status
of the disease in 29 families of DM1 (30 patients and 75 family members)
along with 400 normal individuals of Indian populations by using MDSP-
TPPCR technique. This technique could provide a useful method for
screening DM1 especially in instances where prenatal di-agnosis is required.
Additionally through this study, the molecular spectrum and clinical features
were described in Indian patients and the genotype-phenotype correlation was
investigated. The present findings are helpful not only for laboratory
physicians performing tests and making molecular diagnoses, but also for
clinicians diagnosing and counselling patients with variable onset and
systemic involvement.
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.genrep.2018.01.006.
Abbreviations
DM1 type 1 myotonic dystrophy
DMPK dystrophia myotonica protein kinase
TP-PCR triplet primed PCR
MDRS Muscular Dystrophy Rating Scale
Acknowledgements
We are indebted to the DM families for their cooperation in this study and
thankful to Sanjay Gandhi Post Graduate institute of Medical Sciences
(SGPGIMS), Lucknow for providing infrastructure facility. Dr. Ashok Kumar
is thankful to DBT & DST-New Delhi [DBT-JRF 2009-10/ 515 and DST
NPDF/2015/000951] for providing fellowship.
Funding
No funding was available for publishing the manuscript.
Availability of data and material
All data generated or analysed during this study are included in this
manuscript in main file, Tables and figure (main and supplementary files).
Authors' contributions
The authors alone are responsible for the content and writing of the paper.
Dr. Ashok Kumar is the first and corresponding author and is responsible for
the conception and design of the manuscript. Prof Sarita Agarwal has
conceived the idea and provided financial support for acquisition of the task.
Dr. Sunil Pradhan providing clinical support.
Competing interests
The authors confirm that this article content has no conflicts of interest.
40
Gene Reports 11 (2018) 34–41
Consent for publication
All authors of the manuscript provide their consent for publication in
JBMS journal.
Ethics approval and consent to participate
This study was approved by the Institutional Ethics Committee (2014-
141-PhD-79 PGI/BE/629/26/07/2014). A written informed consent was
obtained from all the individuals.
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