肌肉病臨床研究進(jìn)展

張成 王倞

隨著神經(jīng)科學(xué)技術(shù)的發(fā)展，我國國民經(jīng)濟(jì)和社會發(fā)展第十二個五年規(guī)劃（以下簡稱“十二五”）時期，肌肉病臨床研究，特別是診斷、治療與預(yù)防方面迅速發(fā)展。本文擬就國家“十二五”時期肌肉病臨床研究進(jìn)展進(jìn)行簡要綜述。

一、肌肉病的診斷

1.發(fā)現(xiàn)鑒別診斷幼兒期Duchenne型肌營養(yǎng)不良癥與Becker型肌營養(yǎng)不良癥的生物學(xué)標(biāo)志物假肥大型肌營養(yǎng)不良癥可以分為Duchenne型肌營養(yǎng)不良癥（DMD）和Becker型肌營養(yǎng)不良癥（BMD），前者癥狀嚴(yán)重，病情進(jìn)展迅速，通常于12歲前不能行走、20余歲呼吸功能或心功能衰竭而死亡；后者癥狀輕微，病情進(jìn)展緩慢，12歲后仍可行走，生存期接近正常人群，二者預(yù)后完全不同。然而3～4歲的假肥大型肌營養(yǎng)不良癥患兒均表現(xiàn)為小腿腓腸肌假性肥大、血清肌酸激酶（CK）顯著升高，如何在幼兒期鑒別診斷Duchenne型肌營養(yǎng)不良癥與Becker型肌營養(yǎng)不良癥？中山大學(xué)附屬第一醫(yī)院張成教授研究團(tuán)隊(duì)發(fā)現(xiàn)，酶法檢測肌酐（Cr）水平（成人正常參考值55～153 μmol/L）可以在幼兒期鑒別診斷Duchenne型肌營養(yǎng)不良癥與Becker型肌營養(yǎng)不良癥，血清肌酸水平＜16 μmol/L為Duchenne型肌營養(yǎng)不良癥，＞25 μmol/L為Becker型肌營養(yǎng)不良癥［1?2］，該項(xiàng)研究成果很快被國外同行所引用［3］。

2.肌肉MRI動態(tài)觀察Duchenne型肌營養(yǎng)不良癥病情變化 既往需行肌肉組織活檢術(shù)從病理學(xué)角度評價Duchenne型肌營養(yǎng)不良癥病情變化，創(chuàng)傷較大，患者常難以接受，尤其不能反復(fù)行肌肉組織活檢術(shù)以判斷病情變化和評價治療效果，因此，無創(chuàng)性檢查方法即具有重要意義。隨著肌肉MRI在肌肉病中的應(yīng)用，其判斷Duchenne型肌營養(yǎng)不良癥病情是十分有潛力的，但其臨床應(yīng)用尚待數(shù)據(jù)支持。張成教授研究團(tuán)隊(duì)和北京大學(xué)第一醫(yī)院袁云教授研究團(tuán)隊(duì)分別系統(tǒng)報告我國Duchenne型肌營養(yǎng)不良癥患者肌肉MRI特點(diǎn)，并得到相似結(jié)論，Duchenne型肌營養(yǎng)不良癥患者臀大肌、大收肌、股四頭肌等肌肉受累嚴(yán)重，而縫匠肌、股薄肌等肌肉受累較輕微，證實(shí)肌肉MRI可以反映Duchenne型肌營養(yǎng)不良癥患者肌肉病變情況［4?6]。此后，張成教授研究團(tuán)隊(duì)和武警總醫(yī)院吳士文教授研究團(tuán)隊(duì)對Duchenne型肌營養(yǎng)不良癥患者肌肉MRI能否反映病情嚴(yán)重程度進(jìn)行研究，結(jié)果顯示，T2mapping成像顯示的肌肉病變與運(yùn)動功能顯著相關(guān)，尤其是大收肌，考慮到T2mapping成像是一種相對客觀技術(shù)，故可以客觀、量化、敏感地評價Duchenne型肌營養(yǎng)不良癥病情進(jìn)展［7?8］。吳士文教授研究團(tuán)隊(duì)還通過擴(kuò)散張量成像（DTI）發(fā)現(xiàn)，Duchenne型肌營養(yǎng)不良癥患者存在胼胝體壓部結(jié)構(gòu)改變，這種改變與Duchenne型肌營養(yǎng)不良癥患者認(rèn)知功能障礙密切相關(guān)［9］。

3.完成我國大樣本Duchenne型肌營養(yǎng)不良癥基因型?臨床表型分析，以明確Duchenne型肌營養(yǎng)不良癥和Becker型肌營養(yǎng)不良癥的基因突變規(guī)律和各種突變類型比例 Duchenne型肌營養(yǎng)不良癥是X連鎖隱性遺傳性疾病，致病基因DMD具有多種突變類型，可以分為大片段缺失、大片段重復(fù)和點(diǎn)突變，其中，點(diǎn)突變根據(jù)其對DMD基因轉(zhuǎn)錄翻譯的影響，進(jìn)一步分為無義突變、錯義突變、移碼突變和剪切位點(diǎn)突變等。明確上述突變在我國Duchenne型肌營養(yǎng)不良癥患者中所占比例對了解該病遺傳學(xué)特點(diǎn)、指導(dǎo)臨床治療與遺傳咨詢、研發(fā)基因藥物、制定衛(wèi)生經(jīng)濟(jì)政策具有重大作用；明確基因型與臨床表型的關(guān)系對預(yù)測預(yù)后、指導(dǎo)臨床治療與遺傳咨詢具有重要意義。張成教授研究團(tuán)隊(duì)納入1053例Duchenne型肌營養(yǎng)不良癥患者［10］、福建醫(yī)科大學(xué)附屬第一醫(yī)院王檸教授研究團(tuán)隊(duì)納入407例患者［11］、中南大學(xué)醫(yī)學(xué)遺傳學(xué)國家重點(diǎn)實(shí)驗(yàn)室鄔玲仟教授研究團(tuán)隊(duì)納入613例患者［12］、上海交通大學(xué)醫(yī)學(xué)院附屬新華醫(yī)院蔣雯婷教授研究團(tuán)隊(duì)納入541例男性患者和184例女性攜帶者［13］、復(fù)旦大學(xué)附屬兒科醫(yī)院李西華教授研究團(tuán)隊(duì)納入229例患者［14］、北京協(xié)和醫(yī)院崔麗英教授研究團(tuán)隊(duì)納入89例患者［15］、中國醫(yī)科大學(xué)基礎(chǔ)醫(yī)學(xué)院羅陽教授研究團(tuán)隊(duì)納入119例患者［16］，結(jié)果均顯示，DMD基因氨基末端（N末端）和中央?yún)^(qū)各存在一缺失重復(fù)突變熱區(qū)，然而每項(xiàng)研究發(fā)現(xiàn)的熱區(qū)邊界略有不同，但所在區(qū)域大致相同，缺失突變熱區(qū)位于3～22號外顯子和45～54號外顯子，重復(fù)突變熱區(qū)位于3～11號外顯子和21～37號外顯子；此外，大片段缺失突變占所有突變的53%～70%，大片段重復(fù)突變占9%～17%，其余均為非缺失重復(fù)突變；單外顯子缺失突變發(fā)生率最高位于45～54號外顯子熱區(qū)，主要為51號、45號和49號外顯子；點(diǎn)突變中無義突變比例最高，占40%～50%，其次為微小缺失重復(fù)突變，占32%～37%，剪切位點(diǎn)突變和錯義突變比例較低。上述研究為我國Duchenne型肌營養(yǎng)不良癥的外顯子跳躍治療和無義突變通讀治療奠定重要的數(shù)據(jù)基礎(chǔ)。此外，在基因型?臨床表型分析中，大片段缺失重復(fù)突變與閱讀框理論的符合率為86%～90%，與既往文獻(xiàn)報道基本一致［17?18］。

4.明確遺傳異質(zhì)性很強(qiáng)的肢帶型肌營養(yǎng)不良癥亞型的基因診斷 肢帶型肌營養(yǎng)不良癥（LGMD）是遺傳異質(zhì)性很強(qiáng)的肌肉病，各亞型均表現(xiàn)為四肢近端肌萎縮和肌無力，下肢重于上肢，血清肌酸激酶水平升高，病情逐漸加重，臨床難以區(qū)分各亞型，僅能籠統(tǒng)診斷為肢帶型肌營養(yǎng)不良癥。究其原因，一代基因測序檢測單個基因，無法準(zhǔn)確基于臨床表現(xiàn)選擇應(yīng)檢測何種肢帶型肌營養(yǎng)不良癥亞型基因，唯有突出表現(xiàn)為血清肌酸激酶＞8000 U/L、伴雙側(cè)大腿肌萎縮和肌無力時，提示LGMD2B型，系Dysferlin基因突變所致，僅檢測這一單個基因即可完成基因診斷。隨著二代基因測序技術(shù)的發(fā)展、檢測費(fèi)用的下降和臨床應(yīng)用的廣泛，肢帶型肌營養(yǎng)不良癥各亞型致病基因組成基因測序包，對基因測序包中所有基因進(jìn)行檢測，即可快速明確肢帶型肌營養(yǎng)不良癥亞型，確定致病基因。國家“十二五”時期，我國學(xué)者采用二代基因測序技術(shù)明確LGMD1A型、LGMD1B型、LGMD1E型，LGMD2A型、LGMD2B型、LGMD2D型、LGMD2E型、LGMD2F型、LGMD2H型、LGMD2I型、LGMD2K型、LGMD2L型、LGMD2J型和LGMD2S 型等亞型［19?26］。

5.明確若干罕見性肌肉病的基因診斷 由于罕見性肌肉病的特征是種類繁多、每種疾病數(shù)量少、臨床癥狀與體征相互重疊，故臨床診斷困難，甚至肌肉組織活檢術(shù)亦不能明確疾病類型。國家“十二五”時期，采用二代基因測序技術(shù)對所有已知的遺傳性肌肉病進(jìn)行基因檢測，明確診斷多種罕見性肌肉病，如桿狀體肌病、中央核肌病、線狀體肌病、Magocolia先天性肌病、肌原纖維肌病、Merosin缺失型先天性肌營養(yǎng)不良癥、Ullrich型先天性肌營養(yǎng)不良癥、Bethlem肌病、GNE肌病、常染色體顯性遺傳性包涵體肌病、Emery?Dreifuss型肌營養(yǎng)不良癥、糖原貯積病Ⅱ型、脂質(zhì)沉積性肌病、先天性肌強(qiáng)直、先天性副肌強(qiáng)直、強(qiáng)直性肌營養(yǎng)不良癥、線粒體肌病、周期性麻痹、先天性肌無力綜合征等［27?48］。二代基因測序結(jié)果仍需病理學(xué)檢查的證實(shí)，即基因型與臨床表型相符方明確診斷。由于二代基因測序信息量大，目前的生物信息學(xué)分析以及為臨床醫(yī)師提供規(guī)范、實(shí)用基因檢測報告等方面尚待進(jìn)一步改進(jìn)。

6.探索面?肩?肱型肌營養(yǎng)不良癥的分子診斷及基因型?臨床表型關(guān)系 面?肩?肱型肌營養(yǎng)不良癥（FSHD）是臨床最常見的肌營養(yǎng)不良癥之一，因遺傳學(xué)機(jī)制復(fù)雜，基因檢測相對困難，目前主要以臨床診斷為主。浙江大學(xué)醫(yī)學(xué)院附屬第二醫(yī)院吳志英教授研究團(tuán)隊(duì)探討我國面?肩?肱型肌營養(yǎng)不良癥的分子診斷，結(jié)果顯示，基因檢測過程中區(qū)分4qA和4qB亞型是十分重要的［49］。王檸教授研究團(tuán)隊(duì)對178例中國面?肩?肱型肌營養(yǎng)不良癥患者基因型?臨床表型關(guān)系進(jìn)行研究，結(jié)果顯示，疾病嚴(yán)重程度與長度為3.30×103bp的D4Z4串聯(lián)重復(fù)序列（DRs）相關(guān)，此外，其臨床表型還受包括性別、家族史等其他因素的影響［50］。目前，我國在面?肩?肱型肌營養(yǎng)不良癥分子診斷方面還存在欠缺，能夠開展此項(xiàng)檢測的機(jī)構(gòu)尚不足，是未來亟待解決的問題。

二、肌肉病的治療

1.綜合治療和管理遺傳性肌肉病 目前，絕大多數(shù)遺傳性肌肉病尚缺乏有效治療方法，因此，疾病綜合治療和管理即顯得尤為重要。李西華教授研究團(tuán)隊(duì)在Duchenne型肌營養(yǎng)不良癥的管理方面進(jìn)行多年探索，開展系統(tǒng)的多學(xué)科合作、患者注冊登記、康復(fù)指導(dǎo)、家庭隨訪、心理支持和人文關(guān)懷等，并成立上海市慈善基金會關(guān)愛杜氏肌營養(yǎng)不良兒童專項(xiàng)基金，有眾多志愿者參與，定期舉行病友會活動、傳播最新疾病知識和舉行國際學(xué)術(shù)交流活動等，還組織心理科醫(yī)師對患者及其家屬進(jìn)行針對性心理輔導(dǎo)［14，51］。吳士文教授研究團(tuán)隊(duì)建立Duchenne型肌營養(yǎng)不良癥的多學(xué)科會診模式，進(jìn)行綜合治療和管理（未發(fā)表）。重慶醫(yī)科大學(xué)附屬兒童醫(yī)院蔣莉教授研究團(tuán)隊(duì)提出，Duchenne型肌營養(yǎng)不良癥的發(fā)生與發(fā)展過程中，受累組織器官并非僅限于骨骼肌，亦強(qiáng)調(diào)多學(xué)科協(xié)作模式［52］。張成教授研究團(tuán)隊(duì)也強(qiáng)調(diào)Duchenne型肌營養(yǎng)不良癥的綜合治療，除藥物治療外，呼吸功能和心功能管理、康復(fù)治療、飲食營養(yǎng)支持等一系列措施并舉，以期延長患者生存期和提高生活質(zhì)量［53］。糖皮質(zhì)激素可以有效緩解Duchenne型肌營養(yǎng)不良癥癥狀，然而目前我國尚缺乏相關(guān)臨床數(shù)據(jù)。蔣莉教授研究團(tuán)隊(duì)進(jìn)行隨機(jī)對照臨床試驗(yàn)，共納入66例4～12歲Duchenne型肌營養(yǎng)不良癥患兒，治療組予糖皮質(zhì)激素0.75 mg/（kg·d）口服，治療12個月后肌力、生活質(zhì)量和肌肉超聲均明顯改善［54］。河北醫(yī)科大學(xué)第三醫(yī)院胡靜教授研究團(tuán)隊(duì)納入96例Duchenne型肌營養(yǎng)不良癥患者，予糖皮質(zhì)激素0.50～0.75 mg/（kg·d）口服聯(lián)合地塞米松5～10 mg/d靜脈滴注，治療10～15天后運(yùn)動功能和心肌病變均有所改善［55?56］。上述研究結(jié)果均證實(shí)糖皮質(zhì)激素治療Duchenne型肌營養(yǎng)不良癥安全、有效。

2.罕見性肌肉病醫(yī)療地圖的提出 罕見性肌肉病種類繁多、每種疾病數(shù)量少、分布廣泛、臨床診斷困難、治療效果差，但仍有少數(shù)疾病有特異性治療方法，并可取得良好治療效果。張成教授研究團(tuán)隊(duì)和山東大學(xué)齊魯醫(yī)院焉傳祝教授研究團(tuán)隊(duì)分別發(fā)現(xiàn)，核黃素反應(yīng)性脂質(zhì)沉積性肌病（RR?LSM）患者臨床表現(xiàn)為運(yùn)動不耐受、四肢近端無力、上樓梯和蹲起困難，嚴(yán)重者因吞咽困難而不能進(jìn)食、構(gòu)音障礙、行走不能、床上翻身不能，予維生素B2治療后可行走、上樓梯，甚至可以重新工作［57?58］。解放軍總醫(yī)院吳衛(wèi)平教授研究團(tuán)隊(duì)發(fā)現(xiàn)，低鉀型周期性麻痹（HypoPP）患者晨起或飽餐后出現(xiàn)四肢近端肌無力，補(bǔ)充氯化鉀后癥狀迅速好轉(zhuǎn)［59］。張成教授團(tuán)隊(duì)的研究顯示，糖原貯積?、蛐突颊吲R床表現(xiàn)為病態(tài)疲勞、呼吸困難、四肢近端肌無力和肌萎縮，若早期予Myozyme替代治療，預(yù)后較好［60］。這些可治性罕見性肌肉病，因?yàn)橛刑禺愋灾委煼椒ǎA(yù)后較好，然而臨床實(shí)踐中此類患者十分罕見，且由于臨床罕見，非肌肉病專病醫(yī)師不熟悉其診斷與治療，轉(zhuǎn)診至大醫(yī)院專病門診方可明確診斷，延誤治療，增加醫(yī)療費(fèi)用。如果能夠在患者所在地的二級和三級醫(yī)院進(jìn)行針對性肌肉病專病醫(yī)師培訓(xùn)，此類患者即可就近診斷與治療、咨詢和管理，極大地方便已明確診斷的可治性罕見性肌肉病的治療，亦提高疾病的診斷與治療水平。對于目前尚無特異性治療方法的罕見性肌肉病，應(yīng)轉(zhuǎn)診至有條件的醫(yī)院進(jìn)行診斷與治療。

三、肌肉病的預(yù)防

對于遺傳性肌肉病的預(yù)防，隨著基因檢測技術(shù)的日臻成熟，產(chǎn)前診斷和種植前診斷技術(shù)迅速發(fā)展。以Duchenne型肌營養(yǎng)不良癥為例，存在高度遺傳風(fēng)險的孕婦，可于孕9～12周進(jìn)行絨毛膜穿刺或孕16～20周進(jìn)行羊水穿刺，從而對胎兒遺傳缺陷進(jìn)行檢測。浙江大學(xué)醫(yī)學(xué)院祁鳴教授研究團(tuán)隊(duì)采用實(shí)時聚合酶鏈反應(yīng)（RT?PCR）對4例Duchenne型肌營養(yǎng)不良癥孕婦進(jìn)行產(chǎn)前診斷，結(jié)果顯示，2例孕正常女胎、1例孕正常男胎、1例孕女性攜帶者［61］。亦有多所醫(yī)療中心對Duchenne型肌營養(yǎng)不良癥孕婦的產(chǎn)前診斷進(jìn)行報道，由此可見，產(chǎn)前診斷技術(shù)在我國日臻成熟［61?64］。產(chǎn)前診斷是在妊娠期進(jìn)行的，因此一旦診斷出患病胎兒，需行人工流產(chǎn)術(shù)，這對于高齡孕婦和受孕困難女性而言是難以接受的，種植前診斷技術(shù)則可以彌補(bǔ)其不足。種植前診斷是在體外完成精子與卵子結(jié)合，受精卵發(fā)育到一定時期后，取單個細(xì)胞行基因檢測以判斷受精卵是否存在DMD基因缺陷。臨床實(shí)踐中常利用超數(shù)排卵技術(shù)從女性體內(nèi)獲取多個卵子，分別進(jìn)行體外受精，舍棄存在DMD基因缺陷的受精卵，選擇正常受精卵重新植入女性子宮，最終生產(chǎn)正常嬰兒。張成教授研究團(tuán)隊(duì)采用種植前診斷技術(shù)使1例Duchenne型肌營養(yǎng)不良癥女性攜帶者生產(chǎn)1名正常男嬰和1名正常女嬰，并進(jìn)行4年隨訪觀察，2名幼兒生長發(fā)育、運(yùn)動功能和動態(tài)血清肌酸激酶水平均正常［65］。

四、其他

國家“十二五”時期，我國罕見性肌肉病病友組織與醫(yī)師組織合作開展專病注冊登記，并參與國際神經(jīng)肌肉病協(xié)作組織TREAT?NMD的注冊登記［66］，還于上海市成立上海市罕見病防治基金會。

五、展望

我國國民經(jīng)濟(jì)和社會發(fā)展第十三個五年規(guī)劃（簡稱“十三五”）時期，將進(jìn)一步探討面?肩?肱型肌營養(yǎng)不良癥的新型、直觀、簡便診斷方法，開展Duchenne型肌營養(yǎng)不良癥基因治療如無義突變的PTC124治療、缺失突變的外顯子跳躍治療和用于各種突變的抗肌萎縮蛋白（dystrophin）微小基因替代治療，這些新方法必將有益于我國肌肉病的診斷與治療。

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