Abstract:
A method of screening a subject for mitochondrial dysfunction comprises detecting the presence or absence of single nucleotide changes in a hypervariable region of the mitochondrial DNA of said subject, the presence of such changes indicating that said subject is afflicted with or at risk of developing mitochondrial dysfunction.

Description:
RELATED APPLICATIONS  
       [0001]    This application claims the benefit of U.S. Provisional Application Serial No. 60/184,379, filed Feb. 23, 2000, the disclosure of which is incorporated by reference herein in its entirety. 
     
    
     
       FIELD OF THE INVENTION  
         [0002]    The present invention relates to methods of screening subjects for mitochondrial dysfunction.  
         BACKGROUND OF THE INVENTION  
         [0003]    A wide variety of clinical manifestations are due to mutations in mitochondrial DNA, but are difficult to diagnose due to the varied clinical picture and the lack of sensitive or specific diagnostic testing. Past efforts to document mtDNA mutations in children believed to have mitochondrial disorders have been hampered by the size of the mitochondrial genome and the presence of numerous benign polymorphisms.  
           [0004]    Mitochondria are eukaryotic cytoplasmic organelles where oxidative phosphorylation takes place, and are often termed the ‘power plant’ of the cell. In animal cells, the mitochondria is the only cytoplasmic organelle that contains DNA. Human mitochondrial DNA (mtDNA) is a circular molecule of about 16,600 nucleotide pairs which encode thirteen of the at least 82 protein subunits of the complexes in the oxidative phosphorylation pathway, both ribosomal RNAs, and all of the 22 transfer RNAs required for mitochondrial protein synthesis. However, the majority of proteins located in the mitochondria are encoded by nuclear DNA (chromosomal DNA) and translated by cytoplasmic ribosomes, and then imported to the mitochondria. Therefore, a “mitochondrial disorder” can be secondary to a mutation in either the nuclear DNA or in the mitochondrial DNA.  
           [0005]    The entire human mitochondrial DNA (mtDNA) sequence has been determined (see MITOMAP: Human Mitochondrial Genome Database, Center for Molecular Medicine, Emory University, Atlanta, Ga. USA, http://www.gen.emory.edu/mitomap.html (1998); Wallace et al. (1995) Report of the committee on human mitochondrial DNA, In: Cuticchia A J (Ed)  Human gene mapping  1995: A Compendium, Johns Hopkins University Press, Baltimore, pp 910-954 (1995)).  
           [0006]    Mitochondrial genetics differ from nuclear (standard or Mendelian) genetics. Virtually all the mtDNA of a zygote is derived from the oocyte, and mtDNA disorders are transmitted by maternal inheritance. Maternal-linked (matrilineal) relatives presumably have identical mtDNA sequences, except perhaps at the site of a new mutation. Additionally, the mtDNA mutation rate is substantially higher than that of the nuclear DNA. Most cells contain hundreds to thousands of mitochondria, and each mitochondria contains several copies of mtDNA, resulting in high mtDNA copy number. In normal individuals, essentially all of the mtDNA molecules are identical (homoplasmy). However, if there is a mutation in mtDNA, the mutant mtDNA and the normal (wild type) mtDNA often coexist in the same cell or tissue (heteroplasmy).  
           [0007]    Because of the high mutation rate, mtDNA has numerous polymorphisms. Almost always these polymorphisms are homoplasmic. In contrast, most recognized pathogenic mtDNA mutations are heteroplasmic, especially when disease manifests during childhood (Shoffner and Wallace (1995) In:  The Metabolic and Molecular Basis of Inherited Disease  (7 th  Ed.), New York, McGraw Hill, 1535-1629).  
           [0008]    As a result of segregation in the pre-oocyte stage, each ova of an affected woman has a different proportion of mutant versus normal mtDNA, which can range from virtually 0 to 100%. Each of her children, therefore, will inherit differing amounts of mutant mtDNA. In addition, normal and mutant mtDNA randomly segregate during the cell divisions of embryogenesis, resulting in different proportions of mutant mtDNA residing in different tissues. The presence of clinical disease in a given tissue is dependent on the specific mutation, the percent of mutant mtDNA and the threshold for that tissue. The percentage of mutant mtDNA necessary to cause clinical symptoms varies from tissue to tissue; for example, 80% mutant mtDNA may be clinically silent in liver but cause symptoms in tissues with higher energy requirements, such as muscle or brain (Shoffner et al. (1991)  Adv. Hum. Genet .19:267). Since the mutant mtDNA load varies between matrilineal family members, as well as between tissues within each individual, the clinical manifestations of a mtDNA mutation vary widely among affected family members. Healthy family members with mutant mtDNA levels below threshold are common. These individuals, if female, are ‘carriers’ as their children will inherit their mitochondria and, if inherited mutant mtDNA levels are above threshold, the children will be affected. A well known example is the A3243G mtDNA mutation, in which family subjects exhibit variable manifestations, ranging from stroke (usually associated with relatively higher degrees of mutant heteroplasmy) to those (with lesser mutant loads) with diabetes, deafness, or asymptomatic carriers. This phenomenon of varied clinical presentation has been observed with other mtDNA mutations as well.  
           [0009]    As the mtDNA mutation rate is high, mtDNA disorders may be due to new mtDNA mutations; in such cases matrilineal relatives will be unaffected. In other cases, mothers harbor small degrees of mutant heteroplasmy and are clinically normal or only mildly affected. In a minority of cases, multiple matrilineal relatives harbor various amounts of mutant mtDNA in their tissues and exhibit varying clinical manifestations.  
           [0010]    A broad spectrum of disease manifestations has been associated with systemic mtDNA mutations. These mutations can be either single point mutations, or large rearrangements (deletions and/or duplications). Rearrangements usually are spontaneous, although they may be maternally inherited or mendelianly inherited secondary to predisposing nuclear mutations.  
           [0011]    Mitochondrial disorders are evidenced when the cellular supply of energy is unable to keep up with demand; symptoms predominate in tissues with the highest energy requirements (brain and muscle). Mitochondrial disorders are most commonly displayed as neuromuscular disorders, including developmental delay, seizure disorders, hypotonia, skeletal muscle weakness and cardiomyopathy. Other manifestations which have been reported include gastroesophageal reflux, apnea, optic atrophy, deafness, acute liver failure, diabetes mellitus, and other hormonal deficiencies.  
           [0012]    Mitochondrial disorders are often not suspected until late in a diagnostic work-up. Confirmation of a mitochondrial disorder is, at present, a time-consuming and expensive process, and may include lactic acid measurement in body fluids and diagnostic muscle biopsy for electron microscopy and assay of the electron transport chain activities in vitro. However, these methods rarely specify the mode of inheritance or allow for presymptomatic or prenatal diagnosis.  
         SUMMARY OF THE INVENTION  
         [0013]    A method of screening a subject for mitochondrial dysfunction is disclosed. The method comprises detecting the presence or absence of single nucleotide changes in a hypervariable region of the mitochondrial DNA of said subject, the presence of such changes indicating that said subject is afflicted with or at risk of developing mitochondrial dysfunction.  
           [0014]    Also disclosed is the use of a means for detecting the presence or absence of single nucleotide changes in a hypervariable region of the mitochondrial DNA of a subject in or for determining if that subject is afflicted with or at risk of developing mitochondrial dysfunction.  
           [0015]    The foregoing and other objects and aspects of the present invention are explained in greater detail below. 
       
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0016]    [0016]FIG. 1 shows the pedigrees in patients 1, 6 and 8. Each of the disease manifestations present in these families is consistent with a possible mitochondrial disorder. Squares=males; circles=females; and circles within squares=either gender. Arabic numbers within symbols indicate the number of (normal) individuals. The arrows point to our cases (probands).  
         [0017]    [0017]FIG. 2 shows an expanded diagram of human mtDNA-CR. The mtDNA-CR is defined as the area flanked by the tRNA genes for proline (tRNAP Pro ) and phenylalanine (tRNA Phe ) (boxes with diagonal stripes). The location of each heteroplasmic nucleotide found among the cases described herein are marked by black lines and by the nucleotide number. Although not precisely defined, the approximate locations are noted for the hypervariable regions (HV1 and HV2, box with vertical stripes), evolutionary conserved sequence blocks (CSBs, solid boxes), displacement loop (D-loop, open box), the origin of heavy strand replication (O H ), and the transcription initiation sites for the 2 heavy strand (H1 and H2) and light strand (L) transcripts (arrows indicating the direction of transcription). The cross-hatched boxes at the bottom of the figure depict the areas screened by each of the PCR-amplified segments described herein.  
         [0018]    [0018]FIG. 3 shows a computer scanned image of a TTGE gel of the 7S segment in 5 unrelated individuals: a normal control (lane 1), a child with length heteroplasmy at 16184 (lane 2), two subjects with different point heteroplasmic variants (lanes 3 &amp; 4), and rho negative cell culture (lane 5). As shown here, in the absence of heteroplasmy (homoplasmy) a single distinct band is seen on the gel, while heteroplasmic samples usually demonstrate 3 or 4 bands on TTGE, corresponding to the predicted 2 homoduplex and 2 heteroduplex species (often the homoduplex bands are not separated). 
     
    
     DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS  
       [0019]    The present invention is primarily intended to be carried out on human subjects, including both male and female subjects, of any age, including juvenile subjects. The method may be carried out on subjects who have been previously diagnosed as afflicted with mitochondrial dysfunction, or as a prognostic test on subjects who have not yet been diagnosed as afflicted with mitochondrial dysfunction. The test may be carried out as a screening procedure, wherein a positive result in the test indicates increased risk of mitochondrial dysfunction.  
         [0020]    The mtDNA hypervariable region from which changes or mutations indicative of mitochondrial dysfunction generally consists of hypervariable region HV1 and HV2. Any change or mutation set forth in EXAMPLES hereto may be used in carrying out the test.  
         [0021]    The changes or mutations described herein may be detected by any suitable technique, including but not limited to DNA amplification techniques such as described in U.S. Pat. No. 5,767,248 to Roses et al., the disclosure of which is incorporated herein by reference, adapted to be carried out on the changes or mutations described herein.  
       EXAMPLE 1  
     Inheritance of Mitochondrial Disorders  
       [0022]    Children with idiopathic neuromuscular and/or multi-system disease manifestations are frequently encountered in pediatric tertiary practice. Some of these children bear one or more descriptive diagnoses such as mental retardation, epilepsy, migraine or cardiomyopathy. Increasingly, a proportion of these children are found to have biochemical signs of a possible defect in energy metabolism such as an elevated body fluid lactate, abnormal urine organic acids and/or mitochondrial proliferation by enzyme analysis in muscle. Whether these findings represent primary inborn errors of mitochondrial energy metabolism (‘mitochondrial disorders’) or non-specific secondary phenomenon remains controversial.  
         [0023]    It has been observed that many of these children have matrilineal relatives with widely different, often transient and mild, neuromuscular and/or multi-system manifestations, including migraine (FIG. 1). This observation suggests that a maternally-transmitted factor may be involved in the development of disease manifestations in a substantial proportion of cases. Since mitochondria contain their own DNA (mtDNA) which is maternally transmitted (Shoffner and Wallace (1995) Oxidative phosphorylation diseases. In: Scriver C R, Beaudet A L, Sly W S, Valle D, editors.  The metabolic and molecular bases of inherited disease , 7th ed. New York: McGraw-Hill, pg 1535-629; Chinnery and Turnbull (1997)  Q J Med,  190:657-66), mtDNA sequence variations likely constitute this maternally-transmitted factor. However, known mtDNA mutations are infrequently (&lt;5%) identified in children suspected of having a mitochondrial disorder (Liang and Wong (1998)  Am J Med Genet , 77:395-400), suggesting that additional pathological mtDNA variants remain to be discovered.  
         [0024]    Mitochondrial genetics differs in many aspects from Mendelian, or nuclear, genetics. Mitochondrial DNA is a 16,569 base pair circular molecule which encodes 13 protein subunits of the mitochondrial respiratory chain, as well as the 22 transfer RNA and 2 ribosomal RNA genes required for the translation of the mtDNA-encoded proteins (Shoffner and Wallace (1995) Oxidative phosphorylation diseases. In: Scriver C R, Beaudet A L, Sly W S, Valle D, editors.  The metabolic and molecular bases of inherited disease , 7th ed. New York: McGraw-Hill, pg 1535-629). Mitochondrial DNA exists at high copy number, usually on the order of hundreds or thousands of genomes per cell. Heteroplasmy, defined as the existence of two or more different mtDNA sequences in the same cell, is associated with several, predominantly neuromuscular and/or multi-system disease states in man (Shoffner and Wallace (1995) Oxidative phosphorylation diseases. In: Scriver C R, Beaudet A L, Sly W S, Valle D, editors.  The metabolic and molecular bases of inherited disease , 7th ed. New York: McGraw-Hill, pg 1535-629; Chinnery and Turnbull (1997)  Q J Med , 190:657-66). Over 80 different pathological mtDNA point mutations have been described to date, and the vast majority exist in patients in a heteroplasmic state along with wild-type genomes (Shoffner and Wallace (1995) Oxidative phosphorylation diseases. In: Scriver C R, Beaudet A L, Sly W S, Valle D, editors.  The metabolic and molecular bases of inherited disease , 7th ed. New York: McGraw-Hill, pg 1535-629; Kogelnik et al. (1996)  Nuc Aci Res , 24:177-9 (www.gen.emory.edu/mitomap.html). In contrast, normally occurring mtDNA point sequence variants (polymorphisms) are almost always homoplasmic (only one mtDNA sequence present) (supra). Clinical symptoms occur once the proportion of mutant mtDNA molecules exceeds a threshold which is both tissue and mutation specific (Shoffner and Wallace (1995) Oxidative phosphorylation diseases. In: Scriver C R, Beaudet A L, Sly W S, Valle D, editors.  The metabolic and molecular bases of inherited disease , 7th ed. New York: McGraw-Hill, pg 1535-629; Chinnery and Turnbull (1997)  Q J Med , 190:657-66). Partially in response to varying proportions of mutant and wild-type heteroplasmy among different tissues within each individual and among different family members, maternal inheritance is often characterized by widely variable clinical manifestations, age of onset and severity among members of the same family (supra).  
         [0025]    As the only large non-coding region in the mitochondrial genome, the approximate 1 kilobase (kb) mtDNA control region (CR) is involved in mtDNA replication, transcription and membrane attachment (FIG. 2) (Shoffner and Wallace (1995) Oxidative phosphorylation diseases. In: Scriver C R, Beaudet A L, Sly W S, Valle D, editors.  The metabolic and molecular bases of inherited disease , 7th ed. New York: McGraw-Hill, pg 1535-629; Kogelnik et al. (1996)  Nuc Aci Res , 24:177-9 (www.gen.emory.edu/mitomap.html). Control region mutations which interfere with these and other ‘regulatory’ functions constitute a plausible mechanism for human disease, although disease-causing mutations in this region have not been reported.  
         [0026]    Within the mtDNA-CR are 2 highly polymorphic regions, termed hypervariable region 1 and 2 (HV1, HV2) (supra). A very common HV1 variant consisting of an expanded homopolymeric tract of cytosines (length heteroplasmy) was recently reported as associated with insulin resistance (Poulton et al. (1998)  Diabetologia , 41:54-8). The present study shows the presence of multiple heteroplasmic and homoplasmic single nucleotide changes in the hypervariable regions of the mtDNA-CR in 13 of 67 children with idiopathic neuromuscular and/or multi-system disease manifestations and an elevated body fluid lactate concentration.  
       EXAMPLE 2  
     Case Reports  
       [0027]    Clinical and laboratory findings in each of the 11 children with mtDNA-CR point heteroplasmy patterns on temporal temperature gradient gel electrophoresis (TTGE) are listed in Table 1. Although there is substantial variability in clinical manifestations among the 11 children as a whole, many cases cluster into clinically-based groups, some of which may be syndromic. The following 6 cases were chosen for a more detailed description in order to demonstrate the range of phenotypic expression. Patient 8 was previously reported in brief (Boles and Williams (1999)  Dig Dis Sci , 44 (Suppl.):103S-107S). Pedigrees for patients 1, 6 and 8 are shown in FIG. 1.  
                           TABLE 1                               Patient #1   Patient #2   Patient #3               Brief Clinical   Reversible severe   Reversible severe   Reversible severe       Description   cardiomyopathy   cardiomyopathy   cardiomyopathy       Age/Sex/Race   7/M/B   4/F/H   2/F/H       Heteroplasmy   16168C-T   Insufficient DNA   16093T-C       Growth   Failure-to-thrive,   Early   Short stature           Short stature   failure-to-thrive       Developmental   None   None   Mild       Delay       Seizures   None   None   None       Skeletal Muscle   Hypotonia,   Mild atrophy   Weakness, Fatigue           Weakness, Atrophy       Cardiac Muscle   Dilated   Dilated   Dilated           cardiomyopathy   cardiomyopathy   cardiomyopathy       Gastrointestinal   Chronic diarrhea   Normal   Normal       Other Clinical   Pancytopenia   None   Hydrops,                   Congestive failure       Clinical Course   Improved   Improved   Improved       Highest Lactate   4.8 mM   2.0 mM   2.5 mM       Urine Organic   Ketones   Normal once   Krebs cycle,       Acids           Generalized organic                   aciduria       Cranial Imaging   Not done   Not done   CT:                   Mild atrophy       Muscle Biopsy   Increased variation in   Not done   High citrate           muscle fiber sizes,       synthase           Increased lipid,           High citrate synthase,           Low complex 1, 3, 4       Family History   Maternal history of   Sporadic   Sporadic           migraine                   Patient #4   Patient #5   Patient #8               Brief Clinical   Fasting   Fasting   Migraine/       Description   hypoglycemia   hypoglycemia   dysautonomia       Age/Sex/Race   3/M/C   4/F/C   12/F/C       Heteroplasmy   16481C-T   Insufficient DNA   16176C-T                   16338A-G       Growth   Normal   Normal   Normal       Developmental   None   None   None/gifted       Delay       Seizures   Tonic and absence   None   None       Skeletal Muscle   Episodes of weakness   Normal   Normal           and muscle cramps,           Hypotonia in infancy       Cardiac Muscle   Normal   Normal   SVT       Gastrointestinal   Normal   GER, constipation,   Cyclic vomiting               multiple episodes               of acute               abdominal pain       Other Clinical   3 episodes of   Monitored for   Dilated left ureter,           hypoglycemia   possible sleep   Leg cramps with           and/or altered   apnea,   exercise           mental status   Hypoketotic           with fasting,   hypoglycemia           Chronic fatigue,   with fasting,           asthma   ADHD       Clinical Course   Improved   Improved, except   Improved               for ADHD       Highest Lactate   3.5 mM   Normal once   7.4 mM       Urine Organic   Krebs cycle   Lactate, Ketones,   Lactate, Ketones,       Acids       Free fatty acids,   Krebs cycle               Glutarate       Cranial Imaging   MRI: Increased T2   Not done   Not done           signal in basal           ganglia       Muscle Biopsy   Not done   Not done   Increased variation                   in muscle fiber                   sizes,                   Increased lipid,                   High citrate                   synthase,                   Low complex 1       Family History   Mildly affected   Unknown   Maternal           brother   (adopted)                   Patient #9   Patient #10   Patient #11               Brief Clinical   Mental retardation/   Neonatal severe   Mental retardation/       Description   spasticity   multi-system   spasticity               disease       Age/Sex/Race   5/F/H   0/F/C   5/M/H       Heteroplasmy   16259C-T   16186C-T   HV2           16278C-T (mom)           16288T-C       Growth   Mild short stature   Failure-to-thrive   Short stature,                   Microcephaly       Developmental   Profound   Vegetative   Profound       Delay       Seizures   Probable as infant   Myoclonic   Brief clonic       Skeletal Muscle   Spastic   Hypertonia   Spastic           quadriplegia       quadriplegia       Cardiac Muscle   Normal   Hypertrophic   Normal               cardiomyopathy,               Cardiac arrests       Gastrointestinal   Normal   Esophageal atresia,   Severe GER,               Severe dysmotility   Upper GI bleeding       Other Clinical   Optic atrophy,   Acute renal   Optic atrophy,           Strabismus,   failure,   Cortical blindness           Nystagmus   Multiple   Obstructive sleep               infections,   apnea               Left superior vena               cava and aortic               arch       Clinical Course   Static   Improved, then   Static               died       Highest Lactate   3.5 mM   19 mM   3.6 mM       Urine Organic   Normal once   Lactate, Ketones,   Mild ketones once       Acids       Ethylmalonate,               Krebs cycle,               Generalized               organic               aciduria       Cranial Imaging   MRI:   CT:   MRI:           Leukodystrophy   Thalamic infarcts   Ulegyria       Muscle Biopsy   Not done   Increased variation   Focal increased               in muscle fiber   mitochondrial               sizes,   staining               Low complex 1, 4,               [High citrate               synthase in               sibling]       Family History   Sporadic   Identically   Identically affected               affected male and   male and female               female siblings   siblings who died,               who died,   First cousin parents               HV1 heteroplasmy               in father                   Patient #12   Patient #13               Brief Clinical   Reversible multi-system   Reversible multi-system       Description   disease   disease       Age/Sex/Race   3/F/H   5/F/H       Heteroplasmy   16215A-T   16285C-T       Growth   Failure-to-thrive,   Failure-to-thrive,           Short stature   Short stature       Developmental   Mild   Mild-moderate       Delay       Seizures   Complex partial   In infancy only       Skeletal Muscle   Hypotonia   Normal       Cardiac Muscle   Normal   Normal       Gastrointestinal   Pyloric stenosis,   Gastrostomy           GER, DGE       Other Clinical   Cleft palate   Bronchopulmonary               dysplasia,               Ventilator dependent       Clinical Course   Improved   Improved       Highest Lactate   3.4 mM   5.4 mM       Urine Organic   Lactate, Ketones,   Ketones,       Acids   Krebs cycle   Free fatty acids,               Generalized organic               aciduria       Cranial Imaging   MRI: Normal   Not done       Muscle Biopsy   Increased variation in   Not done           muscle fiber sizes,           Increased lipid,           High citrate synthase       Family History   Maternal   Maternal                                                                          
 
         [0028]    Patient 1 [Transient severe cardiomyopathy]. This child had an unremarkable history until at age 8 months a spider bite became infected which was followed by a loss of developmental milestones. At age 1.5 years an apparent viral upper respiratory and gastrointestinal illness with fasting and dehydration progressed to metabolic acidosis, pancytopenia and dilated cardiomyopathy with congestive heart failure. Developmental delay and failure-to-thrive (FTT) were noted at that time. A mitochondrial disorder was suspected and the child received symptomatic treatment and fasting avoidance. All clinical problems resolved within the next few months except for cyclic neutropenia, which resolved before his third birthday. Currently, at age 7 the child is clinically completely normal, including school performance and cardiac function, except for stable and symmetrical growth retardation (height age=4.7 years). The pedigree is shown in FIG. 1.  
         [0029]    Patient 2 [Transient severe cardiomyopathy]. This child presented at age 6 months with severe dilated cardiomyopathy in congestive heart failure. She was medically treated and listed for transplantation, however, her cardiac function markedly improved on strict fasting avoidance and standard medical therapy. At age 4.5 years she has near normal systolic function and possible mild decreased diastolic function. Mild failure-to-thrive also resolved. Intelligence and physical examination are normal except for a decreased muscle bulk. The family history is unremarkable.  
         [0030]    Patient 4 [Fasting hypoglycemia]. At the age of 13 months, following 10 days of upper respiratory tract symptoms with decreased oral intake, this child was found to be hypoventilating, gray, staring and limp, progressing rapidly to posturing and coma. Temperature was 34.9° C. and serum glucose was 2.2 mM (40 mg/dl) when paramedics arrived; all symptoms resolved immediately following the administration of a glucose-containing intravenous fluid. A very similar event occurred following an eight-hour overnight fast. A disorder of fatty acid oxidation was postulated and fasting precautions were initiated, including 3-4 hours feedings by day and continuous drip feedings by night. No further episodes have occurred, although the child has not been fasted. Gross motor delay, mild hypotonia and growth retardation resolved. At present, the child is asymptomatic except for asthma, occasional staring spells and rare episodes of profound muscle weakness and flank/leg pain during which the child is unable to bear weight for about 2 hours. Family history is remarkable only for a cystic hygroma and similar episodes of muscle weakness, generalized fatigue and an inability to walk in his now 5 year old brother. Their normal parents are not consanguineous.  
         [0031]    Patient 9 [Mental retardation/spasticity]. This child has a static encephalopathy with profound mental retardation, spastic quadriplegia, strabismus and nystagmus. Signs or symptoms of non-neuromuscular tissue dysfunction have been absent. Diagnostic evaluation revealed optic atrophy and leukodystrophy. The family history is unremarkable.  
         [0032]    Patient 10 [Neonatal severe multi-system disease]. This child presented at birth with esophageal atresia and a severe metabolic acidosis refractory to standard treatment. He was transported to the Childrens Hospital Los Angeles facility in severe cardiogenic shock at age 11 days and started on ionotropes for a hypertrophic cardiomyopathy, peritoneal dialysis for acute renal failure and specific therapy for mitochondrial failure. The latter was designed in order to reverse and prevent catabolism and consisted of a continuous infusion of glucose at 10-12 mg/kg/min, insulin at about 0.1 units/kg/hr (titrated to maintain serum glucose between 5-10 mM=90-180 mg/dl), and protein at 1.0 g/kg/d. On this treatment, the anion gap (30 to 14 mM), plasma lactate and renal function normalized, and cardiac function greatly improved within one week. Of note, the lactate remained elevated for several days following the return of normal circulation. The child remained ventilator dependent with chronic lung disease and suffered several cardiac arrests; the last one being lethal at age 4 months. The family history is remarkable for a previous male and female sibling with very similar manifestations (including organic acids and muscle electron transport chain activities in one), who died at ages 3 and 5 months despite intensive support.  
         [0033]    Patient 12 [Reversible multi-system disease]. This child was delivered at 28 weeks gestation following a pregnancy reportably complicated by cocaine and ethanol exposure, although facial morphology appears normal. However, except for chronic lung disease and brief mixed apnea, there were no other complications related to prematurity. The child&#39;s first year was dominated by severe symmetrical FTT and gastrointestinal dysfunction; a fundoplication/gastrostomy and pyloroplasty were performed for gastroesophageal reflux (GER) and pyloric stenosis. Additional problems included complex partial seizures, hypotonia and cleft palate. All of these conditions either resolved or were surgically repaired, and presently at age 3 years her only problem is mild global cognitive delay. Although she remains very small (height and weight age=17 and 13 months, respectively), she now demonstrates a normal growth rate for age. The child was adopted, although her 4 year old maternal half-sister was evaluated and found to have symmetrical FTT with a normal current growth rate, moderate developmental delay, strabismus, and resolved GER.  
       EXAMPLE 3  
     Methods  
       [0034]    Subjects. The experimental group consisted of 67 unrelated children ascertained over a five year period (1994-1999) from the clinical genetics practice of Dr. Richard Boles at Childrens Hospital Los Angeles. All qualifying children were retrospectively recruited based upon the presence of neuromuscular and/or multi-system system disease, an elevated body fluid lactate concentration (usually in plasma and often minimally elevated, &gt;2.0 mM or 18 mg/dl) and the absence of another diagnosis despite an extensive evaluation. This latter evaluation was tailored to each specific child, but always included a high resolution karyotype, urine organic acids, plasma amino acids, Southern blotting for large rearrangements, and PCR for 10 known point mutations (Wong and Senadheera (1997)  Clin Chem  43:1857-61). An additional 14 children that would have qualified were excluded from the study due to the absence of available DNA from a blood sample. No cases were included if ascertainment was based on the referral of a sample to the laboratory for the purpose of mtDNA analysis.  
         [0035]    The control group consisted of 103 unrelated individuals, of which 76 were children of all ages, with definitive diagnoses of non-mitochondrial disorders, including 58 individuals with phenylketonuria (PKU) diagnosed on newborn screening, and 33 and 12 individuals diagnosed by molecular assays with spinal muscular atrophy and Duchenne muscular dystrophy, respectively. There was no reason to believe that any of these conditions were related to mtDNA sequence variations. This study was approved by the CHLA Institutional Review Board.  
         [0036]    Molecular Assays. Total DNA was extracted from blood or hair root and PCR and temporal temperature gradient gel electrophoresis (TTGE) were performed as previously reported (Zoller and Redilla-Flores (1996) Temporal temperature gradient gel electrophoresis of cystic fibrosis samples on the Dcode system. Bio-Rad Laboratories, US/EG Bulletin 2103; Chen et al. (1999)  Clin Chem  45:1162-7; Higashimoto et al. (1999)  Clin Chem  45:2005-6; Wong and Lam (1997)  Clin Chem  43:1241-3). Peripheral blood was assayed in all cases and controls. When available, hair was assayed in the probands and blood and/or hair was assayed in their first degree relatives. The mtDNA control region was divided into 3 segments for TTGE analysis (FIG. 2). TTGE was a relatively novel heteroduplex detection assay which has been shown to be very sensitive in the detection of mtDNA heteroplasmy (including 60 of 60 known cases positively identified (Chen et al. (1999)  Clin Chem  45:1162-7; Chen et al. (1997)  Am J Hum Genet  61:A306 (abstract)). TTGE was also very specific as each heteroplasmic mutation or polymorphism demonstrated a reproducible and distinct band pattern (FIG. 3) (Chen et al. (1999)  Clin Chem  45:1162-7). Heteroplasmy could be detected with proportions as low as about 5% (supra). Ethidium bromide stained TTGE gels were visualized under UV light and imaged with a digital CCD gel documentation system. Percent heteroplasmy for each sequence variant could readily be estimated by the relative intensities of the bands. These measurements could be taken by eye or Gene scan analysis with fluorescent labeled primers and employing the binomial theorem, with results closely agreeing those obtained by denaturing high performance liquid chromatography (Transgenomic WAVE™ DNA Fragment Analysis System, Omaha, Nebr., data not shown).  
         [0037]    For quality assurance, every gel was run concurrently with 1-3 positive controls (known heteroplasmic samples). All assays were repeated starting with the original extracted DNA sample in every case in which heteroplasmy was found in order to exclude PCR artifacts. Pseudogenes were not amplified in any of the segments as determined by the absence of any PCR product (FIG. 3) using primers listed in Table 2 with total DNA extracted from rho negative cell culture (cells lacking any mtDNA (Chomyn et al. (1991)  Mol Cell Biol  11:2236-44), kindly provided by Anne Chomyn at CalTech). Contaminated (i.e. blood transfused) samples were easily detected by the presence of multiple bands (&gt;4) present in multiple mtDNA segments. One such sample was thus identified and removed from this study after confirmation of contamination by HLA typing. Cyclosequencing was performed in all cases with multiple bands seen on TTGE either from a single band cut out from the gel or directly from the original samples, using a dye terminator Cyclosequencing kit (Applied Biosystems) and an Applied Biosystems ABI 373A DNA Sequencer. Haplogrouping was determined by restriction digest and sequencing part of the control region as previously reported (Torroni et al. (1996)  Genetics  144:1835-50).  
                                                                         TABLE 2                       Segment   mtDNA Regions   Nucleotides   Size (bp)   Primer Sequences (5′-3′)   Ta   Ti-Tf, Tr                                7S   Control region   15987-16509   523   upper   CACCCAAAGCT   53   50-62, 3.0           (includes HV1);               AAGATTCTAA           tRNA-Pro               (SEQ ID NO:1)                       lower   AGGCTTTATGAC                           CCTGAAGTA                           (SEQ ID NO:2)       7Sb*   Control region   16200-16509   310   upper   TCCACATCAAAA   53   56-64, 3.0                           CCCCCCCCC                           (SEQ ID NO:3)                       lower   AGGCTTTATGAC                           CCTGAAGTA                           (SEQ ID NO:4)       7Sc*   Control region   15852-16155   304   upper   TCTCCCTAATTG   58   50-59, 3.0                           AAAACAAAA                           (SEQ ID NO:5)                       lower   TGGATTGGGTTT                           TTATGTACT                           (SEQ ID NO:6)       CSB   Control region   16407-560    723   upper   CCTCCGTGAAAT   53   54-61, 3.7           (includes HV2)               CAATATCCC                           (SEQ ID NO:7)                       lower   AAACTGTGGGG                           GGTGTCTTTG                           (SEQ ID NO:8)       F   Control region    500-1190   691   upper   CCCATCCTACCC   56   55-59, 1.0           tRNA-Phe;               AGCACACAC           12S-rRNA               (SEQ ID NO:9)                       lower   GATATGAAGCA                           CCGCCAGGTC                           (SEQ ID NO:10)                                  
 
       EXAMPLE 4  
     Results  
       [0038]    Distinct TTGE band patterns consistent with the presence of a heteroplasmic single nucleotide substitution (‘point heteroplasmy’, FIG. 3) were found in the 7S fragment in 10 of 67 children in the experimental group and in none of the 103 individuals in the control group (p&lt;0.001). In the 8/10 cases in which sufficient DNA was available, sequencing confirmed the presence of at least one point heteroplasmy in hypervariable region 1 (HV1, Table 1, FIG. 2; one mutation was outside of the region commonly referred to as HV1). TTGE analysis in the CSB fragment was consistent with point heteroplasmy in 1 case and in 0 controls; and sequencing revealed a heteroplasmic nucleotide in HV2 (Table 1, FIG. 2). In each case, these base substitutions were previously identified in homoplasmic form as polymorphisms (found in normal individuals) (Kogelnik et al. (1996)  Nuc Aci Res , 24:177-9 (www.gen.emory.edu/mitomap.html); Opdal et al. (1998)  Acta Paediatr  87:1030-44), and many of these polymorphisms have been encountered upon sequencing control individuals in the laboratory (data not shown). Elsewhere in the mtDNA control region, point heteroplasmy was absent in all patients and controls. Multiple cases in both the experimental and control groups were revealed by TTGE and confirmed by sequencing to have polymorphic length variants (length heteroplasmy). Most of these length variants have been previously reported (Bendall and Sykes (1995)  Am J Hum Genet  57:248-56; Torroni et al. (1994)  Am J Hum Genet  55:760-76), although rare or unique variants were also found in at least 2 patients and are the subject of continuing investigation.  
         [0039]    In order to determine whether the observed point heteroplasmic variants were inherited or somatic mutations, samples were assayed from the family members of patients. Consistent with maternal inheritance of mtDNA, in each case in which samples from the mother (patients 4, 6-10, 13), full sibling (patients 4, 6, 9, 10, 13) or maternal half sibling (patient 12) were available, the identical point heteroplasmy was identified by TTGE and/or sequencing. Samples were available from the fathers of patients 1, 4, 6, 7, 9 and 10 and the specific nucleotide variation seen in the proband was absent in each. A distinct HV1 point heteroplasmy was noted in the father of patient 10. DNA was not available from any family members of the child with HV2 heteroplasmy.  
         [0040]    Direct sequencing of the patient or family samples rarely reveals heteroplasmy due to low proportions of the minority sequence (often about 5-25% as estimated by TTGE). The methods employed herein, which involve sequencing of DNA derived from different gel bands, readily reveals the two sequences constituting the heteroplasmic nucleotide identified by TTGE, but this does not exclude the presence of other heteroplasmic nucleotides within the same segment. Careful review of the HV1 sequences revealed probable point heteroplasmy in additional nucleotides in many cases, but not in controls. A second heteroplasmic nucleotide, suspected by sequencing, was confirmed using PCR/allele specific oligonucleotide (ASO) analysis (Wong and Senadheera (1997)  Clin Chem  43:1857-61) in patients 8 and 9 (Table 1). In the latter, further PCR/ASO analyses in the asymptomatic (by history and neurological examination) mother and 11 year old sister revealed the presence of point heteroplasmy at both nucleotides in the mother, and at one site only in the sister (16288T-C). In addition, a third point heteroplasmy was found in the mother, which was homoplasmic for the polymorphism (16278T) in our patient by PCR/ASO. At each heteroplasmic loci, the proportions of each variant were widely different in each family member (and in individual hair roots within each individual), such that almost all direct sequences revealed homoplasmy (single mtDNA sequence present) for one or the other sequence variant.  
         [0041]    In conclusion, reported herein is a novel association of predominately intermittent and non-progressive disease, biochemical signs suggestive of mitochondrial dysfunction, and maternally-inherited mtDNA-CR point heteroplasmy. Pathology is likely mediated through a novel disease mechanism. This disorder is apparently not rare as it was identified in 1/6 children with idiopathic neuromuscular or multi-system disease and an elevated body fluid lactate, a paradigm which is frequently seen in tertiary practice. With highly variable manifestations, this condition(s) will likely be encountered by clinicians in a variety of specialties treating children. Recognition is important, not only to provide the family with a specific diagnosis that in cases without severe neuromuscular disease appears to carry a relatively favorable prognosis, but in many cases to provide appropriate treatment, especially regarding the avoidance of fasting.  
         [0042]    The foregoing is illustrative of the present invention, and is not to be construed as limiting thereof. The invention is defined by the following claims, with equivalents of the claims to be included therein.  
     
       
       
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            1 

cacccaaagc taagattcta a                                               21 

 
           
             2  
             21  
             DNA  
             synthetic construct  
           
            2 

aggctttatg accctgaagt a                                               21 

 
           
             3  
             21  
             DNA  
             synthetic construct  
           
            3 

tccacatcaa aacccccccc c                                               21 

 
           
             4  
             21  
             DNA  
             synthetic construct  
           
            4 

aggctttatg accctgaagt a                                               21 

 
           
             5  
             21  
             DNA  
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            5 

tctccctaat tgaaaacaaa a                                               21 

 
           
             6  
             21  
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            6 

tggattgggt ttttatgtac t                                               21 

 
           
             7  
             21  
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             synthetic construct  
           
            7 

cctccgtgaa atcaatatcc c                                               21 

 
           
             8  
             21  
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            8 

aaactgtggg gggtgtcttt g                                               21 

 
           
             9  
             21  
             DNA  
             synthetic construct  
           
            9 

cccatcctac ccagcacaca c                                               21 

 
           
             10  
             21  
             DNA  
             synthetic construct  
           
            10 

gatatgaagc accgccaggt c                                               21