Mitochondrial myopathies diagnosed in adulthood: clinico-genetic spectrum and long-term outcomes

Mitochondrial myopathies are frequently recognized in childhood as part of a broader multisystem disorder and often overlooked in adulthood. Herein, we describe the phenotypic and genotypic spectrum, and long-term outcomes of mitochondrial myopathies diagnosed in adulthood, focusing on neuromuscular features, electrodiagnostic and myopathological findings, and survival. We performed a retrospective chart review of adult patients diagnosed with mitochondrial myopathy at Mayo Clinic (2005-2021). We identified 94 patients. Median time from symptom onset to diagnosis was 11 years (interquartile range 4-21 years). Median age at diagnosis was 48 years (32-63 years). Primary genetic defects were identified in mitochondrial DNA in 48 patients (10 with single large deletion, 38 with point mutations) and nuclear DNA in 29. Five patients had multiple mitochondrial DNA deletions or depletion without nuclear DNA variants. Twelve patients had histopathological features of mitochondrial myopathy without molecular diagnosis. Most common phenotypes included: multisystem disorder (n=30), mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (14), limb myopathy (13), chronic progressive external ophthalmoplegia (12), and chronic progressive external ophthalmoplegia-plus (12). Isolated skeletal muscle manifestations occurred in 27%. 69% had CNS and 21% had cardiac involvement. Mutations most frequently involved MT-TL1 (27) and POLG (17), however, a wide spectrum of established and novel molecular defects, with overlapping phenotypes, were identified. Electrodiagnostic studies identified myopathy (77%), fibrillation potentials (27%), and axonal peripheral neuropathy (42%, most common with nuclear DNA variants). Among 42 muscle biopsies available, median percentage counts were highest for cytochrome C oxidase negative fibers (5.1%) then ragged-blue (1.4%) and ragged-red fibers (0.5%). Skeletal muscle weakness was mild and slowly progressive (decline in strength summated score of 0.01/year). Median time to gait assistance was 5.5 years from diagnosis and 17 years from symptom onset. Thirty patients died, with median survival of 33.4 years from symptom onset and 10.9 years from diagnosis. Median age at death was 55 years. Cardiac involvement was associated with increased mortality (hazard ratio 2.36 [1.05, 5.29]). There was no difference in survival based on genotype or phenotype. Despite the wide phenotypic and genotypic spectrum, mitochondrial myopathies in adults share similar features with slowly progressive limb weakness, contrasting with common multi-organ involvement and high mortality.