Ribonuclear inclusions as biomarker of myotonic dystrophy type 2, even in improperly frozen or defrozen skeletal muscle biopsies

Myotonic dystrophy type 2 (DM2) is a dominantly inherited disorder caused by a CCTG repeat expansion in intron 1 of ZNF9 gene. The size and the somatic instability of DM2 expansion complicate the molecular diagnosis of DM2. In situ hybridization represents a rapid and sensitive method to obtain a definitive diagnosis in few hours, since it allows the direct visualization of the mutant mRNA foci on skeletal muscle sections. This approach makes the muscle biopsy an important tool for definitive diagnosis of DM2. Consequently, a rapid freezing at ultra cold temperature and a good storage of muscle specimens are essential to avoid morphologic alterations and nucleic acids degradation. However incorrect freezing or thawing may accidentally occur. In this work we report that fluorescence in situ hybridization may be applied on improperly frozen or inappropriately stored muscle biopsies since foci of mutant mRNA are well preserved and can still be detected in muscle sections no more useful for histopathological evaluation.Key words: myotonic dystrophy type 2, defrozen muscle biopsy, fluorescence, in situ hybridization, ribonuclear inclusions.Myotonic dystrophy type 2 (DM2) is a neuromuscular disorder due to the unstable (CCTG)n repeat expansion in intron 1 of the zinc finger protein 9 (ZNF9) gene on chromosome 3q21.3 (Liquori et al. 2001). Mutant ZNF9 pre-mRNA is spliced and polyadenylated, and the mRNA is exported to the cytoplasm where normal levels of ZNF9 protein expression occur (Botta et al., 2006; Margolis et al. 2006); however, the expanded repeats remain in cell nuclei as ribonuclear inclusions (Liquori et al. 2001). The DM2 ribonuclear inclusions contain only the CCUG repeat sequence derived from intron 1 but with no detectable flanking intronic RNA (Margolis et al. 2006). CCUG-containing mutant mRNAs form double-stranded hairpin loop structures that bind specific RNA-binding proteins such as muscle-blind-like proteins (MBNLs) that colocalize with ribonuclear inclusions in myonuclei (Mankodi et al., 2001; Fardaei et al., 2002). Sequestration of these proteins which are regulators of alternative splicing, alters the splicing of several pre-mRNA (reviewed by Osborne and Thornton, 2006) such as the insulin receptor (IR) and the chloride channel (ClC1) (Savkur et al., 2004; Charlet et al., 2002; Mankodi et al., 2002). Alterations in IR splicing leads to insulin insensitivity and predisposition to diabetes (Savkur et al. 2004) and alterations in ClC1 splicing results in electrical myotonia (Charlet et al., 2002; Mankodi et al., 2002). Conventional Southern blot analysis is not adequate for a definitive molecular diagnosis in DM2 due to the extremely large size and somatic instability of the expansion mutation (Liquori et al., 2001; Bachinski et al., 2003). The extraordinary somatic instability complicates the analysis of genotype-phenotype correlations including those in the effect of the gender of transmitting parents and anticipation. The copy number of DM2 CCTG is below 30 in phenotypically normal individuals and up 11.000 in patients (Day and Ranum, 2005). A complex genotyping diagnostic procedure is now commonly used consisting of a three-step molecular protocol (Day et al., 2003; Udd et al., 2003). However, a more practical tool to obtain a definitive diagnosis in few hours is represented by in situ hybridization which detects ribonuclear inclusions in cell nuclei of muscle fibers (Cardani et al., 2004; Sallinen et al., 2004). This approach makes muscle biopsy an essential tool for DM2 diagnosis. For this reason muscle specimens should be sent fresh, for rapid freezing, from the operating room to the pathology laboratory.To avoid RNA degradation, biopsies require special precautions with handling of material, such as immediate freezing of fresh tissues, because retrospective genetic analysis is impaired by conventional tissue processing techniques. However, many small hospitals are ill-equipped for snap freezing which requires access to liquid nitrogen or dry ice; thus, frequently outside hospitals provide specimens that are obscured with freeze artefacts because they either were submitted incorrectly or were improperly frozen, at the point of origin prior to shipment. Moreover, an accidental tissue thawing and refreezing may occur (for example power failure of the freezer) causing severe tissue damages and possible RNA degradation.Here we report our experience on DM2 muscle biopsies improperly preserved: these were no more useful for a histopathological analysis since they showed evident morphologic artefacts, but they proved to be still suitable for diagnosis by fluorescence in situ hybridization (FISH) since ribonuclear inclusions were preserved and still detectable on muscle sections.