X‐chromosome inactivation and 

Duchenne Muscular Dystrophy 
(DMD)
 Learning objectives
• Describe the mechanism of X chromosome inactivation
– Describe which parts of the chromosome is always exempted from inactivation, and that 
recombination in PAR regions are necessary parts of male meiosis
• State and apply the risk for a heterozygote female for showing symptoms of an X‐linked recessive 
disease due to skewed X chromosome inactivation
• Describe the likely X inactivation pattern in a female carrying a translocation of one X chromosome 
and an autosome
• For the most severe X‐linked recessive diseases, state and apply the risk for an isolated case of being 
result of a new mutation versus having inherited the mutation from his mother
• Recognize Duchenne muscular dystrophy as a very severe X‐linked recessive disease caused by 
Dystrophin mutations
– Recognize Becker MD as a mild form of DMD
– Describe DMD and BMB phenotypes
– Compare and contrast the likely mutation types in these two forms
• Discuss the most likely molecular pathological mechanisms for DMD. 
• Describe that due to dystrophin being involved in protein complexes, a patient with DMD‐like 
phenotype has a significant probability for having a different disease

• Sample questions will be available in Osmosis (also if you only use the free version of Osmosis, 
but you need to be registered with your Ross email)
 DMD – the essentials
• X‐linked recessive
• Genetic lethal in males
• Due to lack of Dystrophin protein
• Onset of symptoms before age 5
• Relatively common: 1/4000 – 1/6000 males

• Mild versions = Becker Muscular Dystrophy 
(BMD) – protein present 
 What is the probability that the 
mother is a carrier
*•*.*•pxnxw
1. 1
2. ½
Xny
XX "

3. ¼
4. 2/3
5. 1/3
0% 0% 0% 0% 0%

1 ½ ¼ 2/3 1/3
 What is the probability that the sister 
is a carrier
*
n

*
1. 1
2. ½
xypFEMI.tl/nYxnyXNXexiBii#Ixi
3. ¼
4. 2/3
5. 1/3
0% 0% 0% 0% 0%

1 ½ ¼ 2/3 1/3
The sister has been shown to be a carrier. 
What is her approximate probability for 
showing at least some symptoms?
XNY xnxw
1. 1
XNXN
Xnyxny
2. ½
3. ¼
4. 0
observed at 5- 10%
5. 1/10 blc

0% 0% 0% 0% 0%

1 ½ ¼ 0 1/10
 Answer to previous slide
• Expected: about 0%
• Observed: 5‐10% 
• Explanation is related to X‐chromosome 
inactivation, explained in the next section
X‐chromosome inactivation
(example of epigenetics)
 Why?
• X‐chromosome contains about 2000 genes not 
found in the Y
• For most of these, males and females need 
the same amount of product
• Easiest fix is to inactivate all X chromosomes 
beyond one
 * inactivation
When
occurs ...

• At late blastula (2000‐10000 cells?) stage of 
embryo development
• Each cell inactivates one X independent of 
other cells
• For that cell and all its descendants, X 
inactivation is irreversible
 How?
• Three main players on the X: 
– XIC (X‐inactivation center), physically overlapping 
XIST at Xq13.2
– XIST (X inactivation‐specific transcript) a non‐
coding mRNA of 17 kb 
– its antisense transcript TSIX
 How (2)
• During embryonal development in an embryo 
with 2 X chromosomes:
• The two copies of XIC transiently align
• XIST and TSIX reciprocally get up‐ and down‐
regulated
• On the chromosome with up‐regulated XIST, 
the RNA spreads and covers that chromosome
• This initiates X inactivation
 How (3)
• Downstream events include: 
– DNA methylation 
– Histone modifications
– Accumulation of variant histone 
– Asynchronous replication
– RNA polymerase II exclusion
• Once taken place, XIST expression is no longer 
necessary
• The downstream events are similar to those 
happening in imprinting, and both events are 
examples of epigenetic changes
 has to come from two X chromosomes , indicating
female cut ! ( )
Klinefelter
too
seen though

Calico = Tricolored Cat

B O

B O
 The Tri-colored Cat
• Orange is caused by a X-linked dominant allele at
the O locus
• Black is phenotype if there is no active O alleles
(males, homozygous females, or inactive-X
heterozygotes)
• (White is caused by a dominant autosomal allele
for white spots (ignore this!))
• Tri-colored is called Calico among US cat-lovers
 Expected outcome
• In a woman’s body half the cells express 
Both Xs activated I reactivated in

paternal X, half express maternal X gametes during fetal development

 Equal or Skewed?
• Expected: about 50%
• Arrows point to 
women with very 
unequal X 
inactivation 0% 50% 100%

• Skewed is the word  Percent of cells inactivating the paternal 

X in a large number of women
most frequently used
• May be local or body‐ | .
If mutation

inactivation
Wli inactivation Center

chromosome
of one X leads to

of the
opposite X

wide 2 . Translocation of autosomal material onto X causes inactivation

of the other Xchrom .

different from 50 : too

Skewed inactivation can be caused just by luck of 
( i.e. 40 :
60,70 : 30 m :p ) =
the draw or by some specific mechanisms
Skewed inactivation One of these is mutation in e.g., XIC  
 Consequences of skewed inactivation
• For a woman heterozygote for X‐linked 
disease allele:
– Inactivating the X carrying the good allele in 
majority of cells  expressing disease
– Inactivating the X carrying the bad allele in 
majority of cells  no disease even if allele is 
dominant  reduced penetrance
• Skewed inactivation in whole body or 
regionally
• Skewed X-Chromosome Inactivation
leads to the expression of hemophilia
A in three heterozygous females in
an Atlantic Canadian kindred
• Poster title at the 2005 American Society of
Human Genetics meeting
• Figure title: the severity of hemophilia A in
carrier women correlates with the percentage of
cells expressing the mutant F8 protein
• Heterozygote females have about 5%
risk of expressing disease in most X
linked recessive diseases
 A balanced reciprocal translocations involving X and 8: 
what is consequence of inactivating the translocation X?

1. Cell death
X
2. No problem
3. Faster growth

8 0% 0% 0%

Cell death No Faster
problem growth
 X‐autosomal translocations
Monty

?
;*µx
LESS -
likely

Bfxl
*

t.sk
eraiwhkwlbpamdssion
odmdm

• A carrier of a balanced  :*
:*

translocation will have most cells 
inactivating the normal X
• If she has disease causing allele on  M
DMD
the translocation chromosome,  X
then she will express the disease

8
 Exceptions to X inactivation
• XIST!
• Several genes necessary for normal
reproduction
• Pseudoautosomal regions (PAR)
• Some other genes randomly distributed
within the inactive area (different among
women)
Pseudoautosomal regions (PAR)
X Y
• Identical regions between X and Y PAR1
• PAR1 contains about 13 genes,
PAR2 about 4
• Crossover in PAR1 necessary in male
meiosis PAR 2
– Crossover may happen in PAR2
Duchenne’s Muscular Dystrophy 
(DMD)

gower
's
sign
:
get up off floor this
way due to
hip weakness

↳ not specific to DMD

,
specific to muscle weakness
 Duchenne’s Muscular Dystrophy 
(DMD)
• Typical presenting problem: a boy between 2½ 
and 4 years of age, is or has become more clumsy 
than normal (e.g., dropping things, stumbling and 
falling). Will often show difficulty in jumping or 
climbing stairs. 
• Muscle weakness progresses from proximal to 
distal, involves lower earlier than upper limbs.
• History usually shows developmental milestones 
reached normally until about 2, though mental 
development might be a little behind
 Preview: developmental milestones
(motor)
• 3‐4 month: most fetal reflexes disappear
• 6 month: able to hold a bottle and feed 
• 7 month: can sit unsupported
• 10 month: can stand
• 12 month: walks
• 18 month: walks stairs while holding hand
• 24 month: walks stairs independently
• 3 years: runs well, stands on one foot
• 4 years: skips on one foot, broad jump
Variation among kids, above are averages
 DMD continued
• Gower’s sign typically around age 5‐6
• Inability to walk at 10‐12 years of age
• Death at 16‐20 years of age (the heart is also a 
muscle, as are the muscles that keep the lungs 
going; scoliosis frequent)
• Several other diagnostic signs (look in 
handout/book)
 Becker 's muscular dystrophy

BMD
• Typically presents in a teenager
• Progress slowly
• May never need wheelchair
• Dystrophin present
 Dystrophin Gene
• The gene is huge = 2.3 million basepairs
• The mRNA encoded is 14 kb from 79 exons
• 1/3 of cases involve new mutations meaning is
mother not carrier

• Protein is large, associated with sarcolemma, 
involved in linking extracellular laminin with 
intracellular thin filaments
 Dystrophin mutation types in 
DMD/BMD 
DMD BMD
Deletion % 72% 85%
Deletion types Disrupts 
Conserves 
Several exams at same time
reading frame
reading frame
Point mutations 15‐20%
Less
Partial duplications 6‐10%
6‐10%
Protein Absent
Present but 
usually 
abnormal size
About 10% of patients with DMD/BMD‐like symptoms 
does not have mutation in dystrophin
Dystrophin and associated complexes

Mutation of most of these also result in muscular dystrophies
 Notes for figure
• Sarcoglycans, dystroglycans, etc form a tight 
complex that fall apart if dystrophin is missing
µ most frequent Other than DMD BMD

– Limb girdle muscular dystrophy and other dystrophies 
,

result from mutation in these proteins
• nNOS is a nitric oxide synthase necessary for 
exercise induced vasodilation 
– If missing leads to ischemia in the muscle
• In addition to ischemia, lack of physical coupling 
of cytoskeleton and extracellular matrix is 
probably involved in the pathology of DMD/BMD
 Laboratory
• High creatine kinase is always a sign of muscle 
degradation, and CK is elevated before clinical signs 
become obvious
– Seen in 70% of female heterozygotes for DMD
1. In the DNA lab, PCR amplification, ligation, or southern 
blot can show the presence/absence of single/multiplex 
exons but usually will not detect all
2. If negative, follow up with muscle biopsy for dystrophin
detection
3. If dystrophin absent possible to follow up with e.g., 
sequencing to detect specific mutation and thereafter 
look for carriers in female relatives
Pre‐pregnancy/prenatal counseling of 
female carriers
• Purpose: provide info for reproductive decisions. 
1. Going through with any pregnancy, OR
2. Trying to avoid giving birth to a child with DMD
• Should include
– Explanation of DMD (keep neutral)
– Explanation of options for “2” including risks of such 
options
– Parents can opt out of counseling at any time
– Parents/mother make(s) the final decision
 Re option 2: Prenatal screening
• It is not always possible to test for 
presence/absence of the mutation (if possible 
usually late in pregnancy)
• It is possible to test for sex of fetus very early
• Termination of pregnancy with male fetus is 
one way to ensure not giving birth to child 
with DMD
 Other Similar Diseases
• Becker’s muscular dystrophy
– Caused by other mutations in the DMD gene; 
milder symptoms, later onset
• Limb girdle muscular dystrophy
– Caused by mutations in any of a large number of 
genes
– LGMD1 is autosomal dominant
– LGMD2 recessive inheritance; gene products 
generally interact with dystrophin
The isolated X-linked case: DMD
and other very severe diseases
• Isolated = only one affected in
family
• The mother can be a carrier, XXM XY XX
(2/3)
• OR, the mother can be a non-
carrier, new mutation to blame *
(1/3)
Y XM
• The mother might have gonadal
mosaicism (unknown percentage)
* denotes new mutation
 What is the risk that the sister
(II-1) is a carrier?
XNY
1. 2/3 3

XNXNZ
2. 1/2 xnxt xny
3. 1/3 could be inherited ,
could be new mutation

4. 1/4
5. 1/5 *x¥¥y¥¥
6. 1/6 0% 0% 0% 0% 0% 0%
lz °

2-3 =
tg 2/3 1/2 1/3 1/4 1/5 1/6
 What is the risk that the first
child (III-1) will be affected
XNY XNXN
1. 1/4
2. 1/6 's

by
XNX XNY

XNY
,
1,3

3. 1/8
tz
4. 1/10 °

Thana of
°

tzlboylgirl )
in activating

5. 1/12 Chance

ihhenhhy
of
bad allele
bad X

from mom
0% 0% 0% 0% 0%
tz . 1 .

+2 .

tz =
tz 1/4 1/6 1/8 1/10 1/12