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Original research
Mutation in the MICOS subunit gene APOO (MIC26) associated with an X-linked recessive mitochondrial myopathy, lactic acidosis, cognitive impairment and autistic features
  1. Cristiane Benincá1,2,
  2. Vanessa Zanette2,
  3. Michele Brischigliaro3,
  4. Mark Johnson1,
  5. Aurelio Reyes1,
  6. Daniel Almeida do Valle4,
  7. Alan J. Robinson1,
  8. Andrea Degiorgi5,
  9. Anna Yeates6,
  10. Bruno Augusto Telles4,
  11. Julien Prudent1,
  12. Enrico Baruffini5,
  13. Mara Lucia S. F. Santos4,
  14. Ricardo Lehtonen R. de Souza2,
  15. Erika Fernandez-Vizarra1,
  16. Alexander J. Whitworth1,
  17. Massimo Zeviani1,7
  1. 1Medical Research Council, Mitochondrial Biology Unit, Cambridge, Cambridgeshire, UK
  2. 2Department of Genetics, Federal University of Parana, Curitiba, Paraná, Brazil
  3. 3Department of Biology, University of Padova, Padova, Veneto, Italy
  4. 4Neuropediatric Division, Hospital Pequeno Principe, Curitiba, Paraná, Brazil
  5. 5Department of Chemistry, University of Parma, Parma, Emilia-Romagna, Italy
  6. 6Medical Research Council, Laboratory of Molecular Biology, Cambridge, Cambridgeshire, UK
  7. 7Department of Neurosciences, University of Padova, Padova, Veneto, Italy
  1. Correspondence to Professor Massimo Zeviani, Mitochondrial Biology Unit, Medical Research Council, Cambridge, CB2 0XY, UK; massimo.zeviani{at}


Background Mitochondria provide ATP through the process of oxidative phosphorylation, physically located in the inner mitochondrial membrane (IMM). The mitochondrial contact site and organising system (MICOS) complex is known as the ‘mitoskeleton’ due to its role in maintaining IMM architecture. APOO encodes MIC26, a component of MICOS, whose exact function in its maintenance or assembly has still not been completely elucidated.

Methods We have studied a family in which the most affected subject presented progressive developmental delay, lactic acidosis, muscle weakness, hypotonia, weight loss, gastrointestinal and body temperature dysautonomia, repetitive infections, cognitive impairment and autistic behaviour. Other family members showed variable phenotype presentation. Whole exome sequencing was used to screen for pathological variants. Patient-derived skin fibroblasts were used to confirm the pathogenicity of the variant found in APOO. Knockout models in Drosophila melanogaster and Saccharomyces cerevisiae were employed to validate MIC26 involvement in MICOS assembly and mitochondrial function.

Results A likely pathogenic c.350T>C transition was found in APOO predicting an I117T substitution in MIC26. The mutation caused impaired processing of the protein during import and faulty insertion into the IMM. This was associated with altered MICOS assembly and cristae junction disruption. The corresponding mutation in MIC26 or complete loss was associated with mitochondrial structural and functional deficiencies in yeast and D. melanogaster models.

Conclusion This is the first case of pathogenic mutation in APOO, causing altered MICOS assembly and neuromuscular impairment. MIC26 is involved in the assembly or stability of MICOS in humans, yeast and flies.

  • genetics
  • clinical genetics
  • metabolic disorders
  • neuromuscular disease

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  • Contributors CB performed most of the biochemical, cell biology and microscopy experiments. VZ performed most of the genetics and established patient fibroblast cultures and clinical characterisation of patients. MB performed all the animal model experiments. MJ performed most of the genetics, cloning, small interfering RNA and TnT experiments. AJR performed the exome analysis. DAdV and BAT performed the MRI and clinic characterisation of patients. AY performed the acquisition of TEM images. EF-V performed the in organello import experiments. EF-V and AR contributed with control fibroblasts. EF-V, AR and JP contributed with ideas for the experimental work. CB and MLSFS supervised the clinic characterisation and fibroblast preparation. RLRS and CB supervised the genetics experiments. VZ and RLRS were responsible for ethical approval. AJW supervised the animal model experiments. MZ and CB conceived the project and supervised the experimental workup. CB, MB, EF-V and MZ wrote the manuscript. All the authors contributed to the final version of the paper.

  • Funding This study was financed in by the Core Grants from the MRC (Grant MC_UU_00015/5 to MZ, and MC_UU_00015/6 to AJW), by NRTJ-Institut de France grant (to MZ) and by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) (Finance Code 001 to CB). VZ was supported by a doctoral fellowship from CAPES (Brazil). MB was supported by a doctoral fellowship from the University of Padova (Padova, Italy) and an individual fellowship from 'Aldo Gini' Foundation (Padova, Italy).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Informed consent was obtained from all participants in this study according to ethical standards committee of Federal University of Paraná (CAAE: 84773818.2.0000.0102).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

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