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Huntingtons disease (HD) is an inherited neurodegenerative disorder caused by a polyglutamine stretch in the
huntingtin protein. Today, more than 15 years after the genetic defect underlying HD was discovered, the pathogenesis
is still not well understood and there is no adequate treatment. Research into this disorder has conventionally focused
on neurological symptoms and brain pathology, particularly neurodegeneration in the basal ganglia and cerebral
cortex. Mutant huntingtin is, however, ubiquitously expressed throughout the body. Indeed, contrary to earlier
thinking, HD is associated with abnormalities in peripheral tissues. These abnormal changes are not all secondary to
brain dysfunction, but most seem to be directly caused by expression of mutant huntingtin in peripheral tissues. In
this article, we highlight this emerging eld of research and how it might aect our understanding of the pathogenesis
of this disease, the development of novel biomarkers of disease progression, and the identication of new potential
treatments.
Introduction
Huntingtons disease (HD) research has conventionally
focused on the brain for obvious reasons: HDs core
symptoms include motor abnormalities such as
hyperkinesia and hypokinesia, as well as psychiatric and
cognitive problems (the panel provides an overview of
HD). These symptoms have all been linked to
neurodegeneration in the basal ganglia and cerebral
cortex.
In addition to the classic symptoms, HD is complicated
by other features, such as weight loss and skeletal-muscle
wasting, which are not necessarily directly associated
with changes in brain functions (gure 1). These
features sometimes appear early in the disease course
and can eventually contribute substantially to both
morbidity and mortality. These symptoms have been
suggested to be secondary to general sickness or to be
the consequences of neurological dysfunction. However,
a growing body of evidence indicates that these changes
might be due to the direct eect of mutant huntingtin
(the toxic protein that causes HD) on peripheral tissues.
This thinking is largely derived from recent studies in
animal models of HD, but the fact that similar
abnormalities also occur in peripheral tissues of
patients is gradually becoming evident. In this article,
we propose that an improved understanding of changes
in peripheral tissues in HD could give insight into the
pathogenesis of the disease, lead to discovery of novel
biomarkers of disease progression, and could open new
avenues for treatment.
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Genetic disorder
Autosomal dominant neurodegenerative disorder
Epidemiology
48 per 100 000
Weight loss
Onset
First symptoms can start at any age, but mean age at onset
is between 35 and 45 years
Clinical presentation
Classic neurological symptoms
Motor symptoms
Cognitive deterioration
Psychiatric and behavioural problems
Other clinical presentation features
Weight loss
Atrophy of skeletal muscle
Sleep disturbance
Autonomic disturbances
Cause
A mutation in HTT causes the formation of the mutant
protein huntingtin. Normal individuals have less than 36 CAG
repeats in HTT. Individuals with >39 CAG repeats will develop
Huntingtons disease. Reduced penetrance occurs with
3639 CAG repeats.
Pathogenesis
The role of normal huntingtin is not completely clear, but
when mutated it causes, for example, the formation of
intracellular inclusion bodies, impaired intracellular transport,
defected gene transcription, and apoptosis.
Genetic animal models
Some of the most widely studied mouse models
R6/2: expresses exon 1 of human mutant HTT with about
150 CAG repeats
YAC 72: expresses full-length human mutant HTT with
72 CAG repeats, created using a yeast artical
chromosome as vector
YAC 128: expresses full-length human mutant HTT with
128 CAG repeats, created using a yeast artical
chromosome as vector
N17182Q: expresses the 171 amino acids at the
N-terminal of mutant huntingtin with 82 CAG repeats
HdhQ92: model with 92 CAG repeats knocked in into the
mouse Htt
Other genetic animal models
Caenorhabditis elegans models
Drosophila melanogaster models
Transgenic rhesus macaques
*A comprehensive overview of HD is provided by Walker and colleagues.1
766
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Skeletal-muscle atrophy
Skeletal-muscle wasting is another hallmark of HD.31,32,35,59
The mechanisms underlying muscular atrophy in this
disorder are unclear and, of note, the skeletal muscles
undergo substantial wasting, despite the muscles being
highly active as a result of hyperkinesia.
The muscle wasting is possibly due to defects caused by
the presence of mutated protein in myocytes. Mutant
huntingtin forms inclusion bodies in muscle cells of
R6/2 mice25 and disrupts gene expression similarly to its
eect in the brain.18,19,22 This nding suggests that similar
pathogenetic mechanisms are operative in neurons and
muscle cells. Apart from aecting transcriptional
regulation, mutant huntingtin is known to aect mitochondrial function.60 Studies on cultures of skeletal-muscle
cells from patients with HD revealed several mitochondrial
abnormalities, including respiratory-chain dysfunction,
morphologically abnormal cristae, cytochrome c release,
and apoptosis.6163 In vivo studies also revealed altered
muscle energy metabolism in this disorder.10
Hence, myocytes are aected in HD, possibly as a
direct eect of mutant huntingtin, and muscles undergo
atrophy as a result. This nding opens up new possible
treatment strategies and novel ways of monitoring
disease progression.
Cardiac failure
Cardiac failure occurs in about 30% of patients with HD
(compared with only 2% in age-matched controls) and is a
leading cause of death in these patients.64 Nothing is
known about the pathophysiological mechanism
underlying cardiac failure in this disorder, but failure of
the autonomic nervous system might play a part.65
Alternatively, cardiac failure might be caused by the eects
of mutant huntingtin expression in cardiomyocytes. In
R6/2 mice, the myocardium is atrophic, mitochondria in
cardiomyocytes have abnormal shapes, and cardiac output
is reduced by 50%.66 Cardiomyocyte-specic expression of
polyglutamine fragments with 83 CAG repeats in wild-type
mice induces aggregate formation, autophagy, and
necrotic death of cardiomyocytes, eventually leading to
heart failure.28,29 Taken together, these experimental data
indicate that heart failure in HD could be a direct
consequence of mutant huntingtin expression in
cardiomyocytes, and clinical studies on cardiac tissue of
patients are needed to resolve this matter.
www.thelancet.com/neurology Vol 8 August 2009
Muscle atrophy
Impaired glucose
tolerance
Cardiac failure
Weight loss
Osteoporosis
Testicular atrophy
Testicular atrophy
The highest levels of huntingtin expression are found in
the brain and testes.3,67 Although fertility is unaected in
patients with HD,68 men have reduced testosterone
concentrations69 as well as testicular pathology with
reduced numbers of germ cells and abnormal seminiferous
tubule morphology.70 Reduced plasma concentrations of
testosterone correlate with worsening of the disease.69,71
Similarly, both the R6/2 and YAC128 mouse models of HD
have testicular atrophy, albeit to a greater extent than
patients.70,7275 In R6/2 mice, concentrations of gonadotropinreleasing hormone are reduced, which suggests that the
eects might be secondary to hypothalamic dysfunction.73
In YAC128 mice, however, testicular degeneration develops
before any evidence of decreased testosterone
concentrations or loss of gonadotropin-releasing hormone
neurons in the hypothalamus, suggesting that testicular
pathology results from a direct toxic eect of mutant
huntingtin in the testes.70
Osteoporosis
Data from two preliminary reports suggest that
osteoporosis might also be part of the HD phenotype76,77
and that its severity correlates with the number of CAG
767
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Skeletal muscle
Cardiovascular system
Blood
Morphological
changes
Heart rate
variability
Altered gene
transcription
Mitochondrial
dysfunction
Altered cerebral
blood ow
Mitochondrial
dysfunction
ATP production
Caspase activity
Altered gene
transcription
Inammatory
markers
(eg, interleukin 6)
Skeleton
Digestive tract
Insulin
production
Osteoporosis
Altered gene
transcription in
islet cells
Genital system
Thyroid
Testosterone
(men only)
Levels of T3
Number of
spermatids
Diameter of
seminiferous
tubules
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Skeletal muscle
Cardiovascular system
Blood
Morphological
changes
Cardiac output
Altered gene
transcription
Mitochondrial
dysfunction
Protein nitration
Mitochondrial
dysfunction
ATP production
Thickness of myocardium
Altered gene
transcription
Inammatory
markers
(eg, interleukin 6)
Caspase activity
Bone
Bone density
Digestive tract
Inclusion bodies
Loss of
ghrelin-producing
neurons
Inclusion bodies
Leptin and
adiponectin
Urea cycle
deciency
Genital system
Testosterone
and GnRH
Testicular atrophy
Dysorganised
seminiferous
epithelium
Insulin, glucagon,
somatostatin
production
Inclusion bodies
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Contributors
JMMvdB initiated the project, drafted the rst version of the Review, and
composed the panel and gures. MB and PB contributed with additional
sections and, together with JMMvdB, edited later editions of the paper.
All authors agreed on the nal version of the review.
Conicts of interest
We have no conicts of interest.
Acknowledgments
We are active in a research environment that is sponsored by three
network grants that have HD as one of their themes, namely
NeuroFortis (Swedish Research Council Strong Research Environment),
The Nordic Center of Excellence on Neurodegeneration, and
BAGADILICO (Swedish Research Council Linnaus Grant). All these
grants have contributed to the intellectual environment that has made
this article possible.
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