Molecular Diagnostics

The proportion of mutant mtDNA may vary widely depending on the type of tissue sampled [49], which presents
both diagnostic and prognostic dilemmas for clini- cians. Blood leukocytes have traditionally been the most common
specimens ana- lyzed through molecular diagnostics, although individuals may have detectable mutation in muscle cells
but undetectable mutant load in blood [50, 51]. Urine sedi- ment, cheek mucosa, and skin fibroblasts are also frequently
assayed. Urine sedi- ment cells and cheek mucosa tend to carry the highest mutation loads and therefore may be more
suitable tissues for the diagnosis of a mitochondrial mutation [49].
Several methods have been developed for mutation detection and quantification. These include polymerase chain
reaction (PCR) with restriction enzyme digestion followed by gel electrophoresis and band intensity quantification
(PCR-restriction fragment length polymorphism) [52], PCR with peptide nucleic acid clamp and sequencing [53], and
PCR with subsequent hybridization using allele-specific oligonucleotide probe [54]. The preferred technique is
quantitative real-time PCR with allele-specific primers [55]. Other techniques include PCR with a fluorescence- labeled
primer followed by restriction enzyme digestion, separation, and detection by capillary electrophoresis [56].

Treatment

There are no curative treatments for mitochondrial disease. Therapeutic options for MELAS and other
mitochondrial cytopathies remain anecdotally supported without compelling or definitive evidence of efficacy. A trial
assessing the role of dichloro- acetate in the treatment of MELAS was terminated prematurely due to a significant
incidence of peripheral nerve toxicity within the treatment group [57]. The wide- spread and unexpected toxicity of this
agent contrasted sharply with the significant benefit of dichloroacetate reported in open-label, uncontrolled studies,
providing a striking note of caution to those endorsing therapies based on empiric usage and open-label study.
Symptomatic management (i.e., addressing cardiac, renal, growth, and nutritional issues and treating seizures) remains
the mainstay of therapy. Supplementation with a so-called mitochondrial cocktail is commonly prescribed in basic care
for children and adults with mitochondrial diseases.
The “mitochondrial cocktail” strategy is designed to maximize function of the OXPHOS pathway and reduce
oxidative stress. While the specific composition of cofactors and supplements varies widely among practitioners,
most treatment regimens involve a combination of creatine, coenzyme Q10, and alpha-lipoic acid, in addition to
vitamin supplementation of riboflavin, thiamine, vitamin C, vitamin E, and biotin. Improved muscle strength during
aerobic activity following supplemen- tation with creatine monohydrate has been reported in mitochondrial disease
patients [58–60]. Studies utilizing coenzyme Q10 have been somewhat conflicting, with some reporting benefits [61–
64] and other larger studies failing to replicate initial positive findings [65, 66]. Numerous case reports, open trials, and
retrospec- tive studies of various combination therapies appear in the literature [67]. However, there is a paucity of
randomized controlled trial data demonstrating efficacy of this approach and no consensus regarding appropriate dosing
of the respective cofac- tors, supplements, and vitamins that comprise the cocktail.
Idebenone, an analog of coenzyme Q10, has also gained attention as a potential therapy in mitochondrial disease in
general and MELAS in particular [64]. This agent is approved in Canada for the treatment of Friedreich ataxia, a disease
of the mitochondria. Frataxin, the defective protein in Friedreich ataxia, is implicated in mitochondrial iron-sulfur
metabolism [68].
As mentioned, anecdotal reports have emerged suggesting a possible role for l-arginine in the modulation of the
vascular symptoms of MELAS syndrome. Paradoxically increased COX activity and its effect on NO levels may
underlie the angiopathy and stroke-like episodes that typify MELAS syndrome. In addition, l-arginine may affect the
uptake of glutamate and release of gamma-aminobutyric acid, resulting in increased production of ornithine [69].
Recognizing this potential association, individual case reports [70, 71] and a small case series [72] have reported the
value of intravenous l-arginine supplementation in reducing the sever- ity of stroke-like events in an acute setting.
Another case report monitored the effects of oral l-arginine taken with idebenone over 27 months suggesting long- term
safety and prevention of stroke-like episodes [73]. In a larger prospective trial, though unblinded and unrandomized, l-
arginine given as an oral supplement over a period of up to 2 years was noted to significantly improve endothelial
function [36], with normalization of flow-mediated systemic arterial vasodilation and improved cerebral blood flow.
More recently, a small case control study suggested improve- ment in aerobic capacity and muscle metabolism by
supplementation [74]. Stable isotope infusion techniques have found that citrulline is superior to arginine in increasing
NO production, potentially having a greater therapeutic effect in patients with MELAS [75, 76].
Oral taurine supplementation has also come under consideration for the preven- tion of stroke-like episodes in
MELAS. As discussed, deficiencies in post- transcriptional taurine modification affects wobble pairing and disrupts the
ability to decipher codons thereby affecting mitochondrial protein synthesis [77]. The supplementation of taurine
improved oxygen consumption in MELAS cybrid cells and prevented new stroke-like episodes in two reported patients
[78].
The administration of corticosteroids in acute events to enable recovery has been recommended. IV
dexamethasone was given in the case of a 10-year-old girl who presented with acute onset headache, vision changes,
and right arm shaking. The function of corticosteroids in acute management is believed to stabilize the blood- brain
barrier, reduce tissue edema, and improve perfusion to damaged areas of the brain [79]. Alternatively, regional
hyperperfusion during a stroke-like event may lead to neuronal loss in the first place, warranting corticosteroid use to
decrease inflammatory processes and prevent further cell damage [80]. Whatever the mecha- nism, the efficacy and role
of this intervention has yet to be clarified.
The ketogenic diet, which utilizes fat rather than glucose as the primary fuel of cell energy production, is
traditionally used for the treatment of refractory epilepsy. However, one case report hypothesizes benefits of this diet in
MELAS patients through the improved function of respiratory chain complexes, thereby affecting seizure control and
decreasing stroke-like episodes [81].
Lastly, prevention of MELAS may become an option in the future by way of preimplantation genetic diagnosis or
tRNA gene modification. Female carriers wishing to conceive a healthy child free of inherited mitochondrial disease
may undergo preimplantation genetic diagnosis to select for an embryo with mutation percentage below the threshold of
clinical expression [82]. In another study, the introduction of recombinant tRNA encoding human mitochondrial leucyl-
tRNA synthetase into affected human cybrid cells resulted in improved mitochondrial translation, production of cell
respiratory complex subunits, and cellular respiration [83]. These reports target the molecular pathogenesis of MELAS
and represent possible therapy in the future. Yet, accessibility and cost are just two among many issues barring the
practicality of gene-based intervention at this time.