Anoctamin-5 related muscle disease: clinical and genetic findings in a large European cohort
Authors: de Bruyn Alexander , Montagnese Federica , Holm-Yildiz Sonja , Scharff Poulsen Nanna , Stojkovic Tanya , Behin Anthony , Palmio Johanna , Jokela Manu , De Bleecker Jan L , de Visser Marianne , van der Kooi Anneke J , ten Dam Leroy , Domínguez González Cristina , Maggi Lorenzo , Gallone Annamaria , Kostera-Pruszczyk Anna , Macias Anna , Łusakowska Anna , Nedkova Velina , Olive Montse , Álvarez-Velasco Rodrigo , Wanschitz Julia , Paradas Carmen , Mavillard Fabiola , Querin Giorgia , Fernández-Eulate Gorka , Quinlivan Ros , Walter Maggie C , Depuydt Christophe E , Udd Bjarne , Vissing John , Schoser Benedikt , Claeys Kristl G 
Published: March 2023

Abstract
Anoctamin-5 related muscle disease is caused by biallelic pathogenic variants in the anoctamin-5 gene (ANO5) and shows variable clinical phenotypes: limb-girdle muscular dystrophy type 12 (LGMD-R12), distal muscular dystrophy type 3 (MMD3), pseudometabolic myopathy or asymptomatic hyperCKaemia.
In this retrospective, observational, multicentre study we gathered a large European cohort of patients with ANO5-related muscle disease to study the clinical and genetic spectrum and genotype–phenotype correlations.
We included 234 patients from 212 different families, contributed by 15 centres from 11 European countries. The largest subgroup was LGMD-R12 (52.6%), followed by pseudometabolic myopathy (20.5%), asymptomatic hyperCKaemia (13.7%) and MMD3 (13.2%). In all subgroups, there was a male predominance, except for pseudometabolic myopathy. Median age at symptom onset of all patients was 33 years (range 23–45 years). The most frequent symptoms at onset were myalgia (35.3%) and exercise intolerance (34.1%), while at last clinical evaluation most frequent symptoms and signs were proximal lower limb weakness (56.9%) and atrophy (38.1%), myalgia (45.1%) and atrophy of the medial gastrocnemius muscle (38.4%). Most patients remained ambulatory (79.4%). At last evaluation, 45.9% of patients with LGMD-R12 additionally had distal weakness in the lower limbs and 48.4% of patients with MMD3 also showed proximal lower limb weakness. Age at symptom onset did not differ significantly between males and females. However, males had a higher risk of using walking aids earlier (P = 0.035). No significant association was identified between sportive versus non-sportive lifestyle before symptom onset and age at symptom onset nor any of the motor outcomes. Cardiac and respiratory involvement that would require treatment occurred very rarely. Ninety-nine different pathogenic variants were identified in ANO5 of which 25 were novel. The most frequent variants were c.191dupA (p.Asn64Lysfs*15) (57.7%) and c.2272C&gt;T (p.Arg758Cys) (11.1%). Patients with two loss-of function variants used walking aids at a significantly earlier age (P = 0.037). Patients homozygous for the c.2272C&gt;T variant showed a later use of walking aids compared to patients with other variants (P = 0.043).
We conclude that there was no correlation of the clinical phenotype with the specific genetic variants, and that LGMD-R12 and MMD3 predominantly affect males who have a significantly worse motor outcome. Our study provides useful information for clinical follow up of the patients and for the design of clinical trials with novel therapeutic agents.