Proc. Natl. Acad. Sci.

USA
Vol. 89, pp. 6457-6461, July 1992

Medical Sciences

Molecular basis of AMP deaminase deficiency in skeletal muscle

TAKAYUKI MORISAKI*t, MANFRED GROSS*tt, HIROKO MORISAKI*t, DIETER PONGRATZ, NEPOMUK ZOLLNERt,
AND EDWARD W. HOLMES*t
*Departments of Medicine and Biochemistry, Duke University Medical Center, Durham, NC 27706; tDepartments of Medicine and Human Genetics, Seymour
Gray Molecular Medicine Laboratory, University of Pennsylvania, Philadelphia, PA 19104-4283; tMedizinische Poliklinik der Universitat Munchen, Munich,
Federal Republic of Germany; and Friedrich-Baur-Institut bei der Medizinischen Klinik der Universitat Munchen, Munich, Federal Republic of Germany
Communicated by James B. Wyngaarden, April 9, 1992

inherited defect in the AMPDJ gene since the enzyme deficiency has been reported in several members of the same
family (13, 20). However, acquired deficiency of AMPD has
also been described (14), raising the possibility that the
absence of AMPD activity may be secondary to other abnormalities. To determine the molecular basis for this potentially common abnormality we have studied 11 unrelated
individuals with AMPD deficiency. All of these individuals
are homozygous for the same mutant allele. In randomly
selected Caucasians and African-Americans we have found
this mutant allele in 13% of 144 alleles tested, but we have not
found this mutant allele in 106 DNA samples from Japanese
subjects.

AMP deaminase (AMPD; EC 3.5.4.6) is enABSTRACT

coded by a multigene family in mammals. The AMPDI gene is
expressed at high levels in skeletal muscle, where this enzyme
is thought to play an important role in energy metabolism.
Deficiency of AMPD activity in skeletal muscle is associated
with symptoms of a metabolic myopathy. Eleven unrelated
individuals with AMPD deficiency were studied, and each was
shown to be homozygous for a mutant allele characterized by
a C -. T transition at nucleotide 34 (codon 12 in exon 2) and
at nucleotide 143 (codon 48 in exon 3). The C -* T transition
at codon 12 results in a nonsense mutation predicting a severely
truncated AMPD peptide. Consistent with this prediction, no
immunoreactive AMPD1 peptide is detectable in skeletal muscle of these patients. This mutant allele is found in 12% of
Caucasians and 19% of African-Americans, whereas none of
the 106 Japanese subjects surveyed has this mutant allele. We
conclude from these studies that this mutant allele is present at
a sufficiently high frequency to account for the 2% reported
incidence of AMPD deficiency in muscle biopsies. The restricted distribution and high frequency of this doubly mutated
allele suggest it arose in a remote ancestor of individuals of
Western European descent.

METHODS AND MATERIALS

Patients. The index case for these studies is an 18-year-old
German female, who first noted calf pain at 4 years of age,
usually related to exercise. Persistence of these symptoms
along with weakness of the upper arms eventually led to a
muscle biopsy, which exhibited absence of AMPD activity
with normal phosphorylase and phosphofructokinase activities. This patient's muscle biopsy, as well as DNA samples
from other family members, was studied in detail. Muscle
biopsies or DNA samples from 10 other unrelated individuals
with AMPD deficiency and variable symptoms (Table 1) were
also analyzed. All patients were identified and referred to us
because muscle biopsies performed for the indicated symptoms (Table 1) were found to have reduced levels of AMPD
activity. DNA samples from 59 Caucasians, 13 AfricanAmericans, and 106 Japanese were obtained from normal
volunteers or from investigators who had no knowledge of
the donors' medical history.
Protein Analyses. AMPD activity was quantified either by
a radiochemical assay or by a spectrophotometric assay (5),
and the method employed is noted in the text or figure legend.
Immunoblots were performed with antiserum raised to
AMPD purified from rat skeletal muscle (5) using an enhanced chemiluminescence detection system (Amersham).
Nucleic Acid Analyses. Northern hybridization of RNA
extracted from skeletal muscle was performed as described
from this laboratory (3). First-strand cDNA (22) was synthesized from patient-derived RNA samples using an oligonucleotide complementary to bases 2239-2258 (5'-TTGGTTTACTTTTTTTTATTC-3') in this 2.3-kilobase (kb) mRNA
(the sequence of human AMPD is reported in ref. 23).
Single-strand cDNA was amplified by the polymerase chain
reaction (PCR) (24, 25) in two separate reactions; oligonucleotides corresponding to bases -20 to -1 (5'-AATCAAGGATCCCAGCAACA-3') and 881-900 (5'-CACCTTCCTGCAGTTATAAA-3') were used to synthesize the 5' region;

AMP deaminase (AMPD; EC 3.5.4.6), an enzyme that catalyzes deamination of AMP to IMP, and the purine nucleotide cycle, of which AMPD is one component, play a central
role in purine nucleotide interconversion in eukaryotic cells.
As a consequence, AMPD activity can be a determinant of
adenylate energy charge and energy metabolism in the cell (1,
2). In mammals, AMPD is encoded by a multigene family (3),
which accounts in part for the tissue-specific and stagespecific isoforms of AMPD that have been identified (4, 5).
The activity of AMPD in skeletal muscle is -100 times higher
than that of other organs, a consequence of the high level of
expression of the AMPDJ gene in this tissue (1, 4, 5).
Since Fishbein et al. (6) first reported 5 patients with
AMPD deficiency, >100 patients with this enzyme defect
have been described (7-21). Several centers have reported
AMPD deficiency in up to 2% of randomly selected muscle
biopsies (6, 7, 9, 12). A review of reported cases of AMPD
deficiency noted that 88% of these individuals with AMPD
deficiency describe exercise-related symptoms, including
muscle aches, cramps, and early fatigue (1). Symptoms are
variable, however, with some reports of asymptomatic individuals and descriptions of other patients who exhibit a range
of neuromuscular disorders. In the few patients studied in
detail (6, 17, 18), the deficiency of AMPD activity has been
restricted to skeletal muscle, consistent with high-level expression of the AMPD1 gene being restricted to skeletal
muscle (3, 4).
The molecular basis for AMPD deficiency is not known,
but in some individuals it is presumed to be the result of an

Abbreviation: AMPD, AMP deaminase.

ITo whom reprint requests should be addressed at: Department of
Medicine, University of Pennsylvania, 100 Centrex, 3400 Spruce
Street, Philadelphia, PA 19104-4283.

The publication costs of this article were defrayed in part by page charge
payment. This article must therefore be hereby marked "advertisement"
in accordance with 18 U.S.C. 1734 solely to indicate this fact.
6457

6458

Proc. Natl. Acad Sci. USA 89 (1992)

Medical Sciences: Morisaki et al.

Table 1. AMPD-deficient patients

AMPD activity,*
Clinical presentation
units/g
Patient Sex Age, years
9
5.4
Calf pain and muscle weakness
18
lt
Progressive weakness and cramps in legs
9
12.5
2
16
25
18.8
3
Rhabdomyolysis after viral infection
4
Pain in both legs after exercise
31
13.5
d
32
8.8
5
Easy fatigue and pain in both legs
d
45
6.2
Pain in both arms after exercise
6
9
45
4.4
Pain in arms and shoulders after exercise
7
Right shoulder pain after exercise
51
3.4
8
d
6.6
9
53
Weakness and pain in legs during exercise
d
Muscle pain after exercise
8.3
62
d
10
9
68
0
Pain in arms and legs aggravated by exercise
11
*AMPD activity normal range is 60-300 units/g of noncollagen protein.

Age at onset of
symptoms, years
4
11
25
30
29
41
33
50
50
55
55

tIndex case.

oligonucleotides corresponding to bases 881-900 (5'TTATAACTGCAGGAAGGTG-3') and bases 2239-2258 (5'TTGGTTTACTTTTTTTTATTC-3') were used to synthesize the 3' region. This approach was selected to reduce the
probability of errors induced by PCR of long DNA sequences
(26) and to facilitate functional analysis of individual mutations that might be found in the 5' and 3' regions of this
transcript. PCR products were subcloned into pBS (Stratagene) for sequencing by the dideoxynucleotide chaintermination method (27). Thirty independently isolated pBS
subclones were pooled for initial sequencing to obviate
PCR-induced errors. Mutations identified by this screening
procedure were subsequently confirmed by sequencing this
region in individual clones. The PCR products were also
subcloned into a prokaryotic vector, pKK233-2 (Pharmacia),
for expression in Escherichia coli. This approach permits a
rapid functional analysis of mutations since prokaryotes do
not exhibit AMPD activity. Genomic DNA, isolated from
patients and volunteers by standard methods (22), was amplified by PCR with oligonucleotides corresponding to intron
1 and intron 2 (5'-GCAATCTACATGTGTCTACC-3') and
5'-ATAGCCATGTTTCTGAATTA-3') for evaluation of
exon 2; oligonucleotides corresponding to intron 2 and intron
3 (5'-AGCAGAAACTCTCAGCTGAC-3' and 5'-CTCCTTAGGTGCCAATATAC-3') were used for evaluation of
exon 3. These PCR products were analyzed by direct sequencing (28), hybridization with allele-specific oligonucleotides (29), and/or restriction analysis as described in the
text.

RESULTS
Evaluation of Index Family. AMPD1 transcript size is not
detectably altered in skeletal muscle from the index patient,
and transcript abundance is not reduced (Fig. 1). To the
contrary, the AMPD1 transcript, when normalized to creatine kinase M abundance, is approximately three times
greater in this patient than a normal control. Studies of a
heterozygote for AMPD deficiency also demonstrate that the
mutant AMPD1 transcript is present in greater abundance
than the wild-type transcript (unpublished observations).
Comparison ofthe cDNA sequence for the index patient to
that for a normal control reveals only two nucleotide differences (Fig. 2). Numbering from the first in-frame AUG, the
presumptive translation start site, nucleotide 34 is a T in the
patient and it is a C in the control; nucleotide 143 is a T in the
patient and it is a C in the control. The deviation in sequence
of the patient cDNA at position 34 (exon 2) changes this
codon from CAA to TAA-i.e., a stop codon instead of
glutamine. The sequence difference at position 143 (exon 3)
in the patient predicts an amino acid substitution of a leucine
for proline.

To evaluate the significance of the missense mutation at

position 143, wild-type and mutant cDNAs were ligated into
a prokaryotic expression vector (pKK233-2) and E. coli
lysates were assayed for AMPD activity. The 5' terminal 133
nucleotides of the mutant cDNA were replaced with the
wild-type sequence to remove the nonsense mutation at
position 34, resulting in a cDNA that had the single C -+ T
mutation at position 143. Prokaryotes do not exhibit detectable AMPD activity and any activity in the lysate from E. coli
transformed with the expression vector is presumably derived from the plasmid introduced into E. coli. This was
confirmed by immunoprecipitation of the AMPD activity
using an antiserum specific for the AMPDJ gene product (5).
E. coli transformed with the wild-type cDNA exhibit AMPD
activity in the range of 2-8 munits/mg of protein, and the
AMPD activity in lysates from E. coli transformed with the
cDNA mutated only at position 143 is not detectably different.

Although the mutation at position 143 appears to have little

effect on catalytic activity of AMPD, the nonsense mutation
at position 34 in this patient would be expected to give rise to
a severely truncated peptide, only 11 amino acid residues
compared to 747 residues in the control. Muscle extract from
this patient has no detectable immunoreactive AMPD using
polyclonal antiserum, whereas an easily detectable 86-kDa
band is visualized in muscle extract from the normal control
using this antiserum (Fig. 3). Deletion and point mutation
analyses of human AMPD1 have shown that the active site
for catalysis in this enzyme is located 3' to nucleotide 531,
codon 177 (unpublished observation). Thus, the nonsense
mutation at position 34 would be expected to result in
complete loss of AMPD activity, and the absence of immunoreactive protein can also be explained by this mutation.
Genomic DNA from the index patient's mother, father, and
brother, all of whom are asymptomatic, was also sequenced
Ct Pt

AMPD
DI --m

CK-M FIG. 1. AMPD1 mRNA abundance in muscle. Four micrograms

of total RNA from control muscle (Ct) and muscle from the index
patient (Pt) was resolved on a 1% agarose gel containing formaldehyde, transferred to Nytran paper (Schleicher & Schuell), and
hybridized with a human AMPD1 cDNA probe (AMPD1) (23). After
washing the filter, the same filter was used for hybridization with a
human creatine kinase M (CK-M) cDNA probe (30).

Medical Sciences: Morisaki et al.

Proc. Natl. Acad. Sci. USA 89 (1992)

6459

Exon 2

Exon 3

Exon 2

PATIENT

CONTROL
GATC

3,
G

GATC

A
G

"/

G
T
T
A
A Stop

-A-

A
A

34

Cl

A
A
A

IG
T

Exon 3
PATIE N T

CONTROL
GATC

\G
A

GATC

5,

.t ws'

FIG. 2. Nucleotide sequence of cDNA and gene for AMPD1. (A) Sequence of AMPD1 cDNA from a control and the index patient. The left
panel shows the mutation in exon 2 (C-. T at nucleotide 34) that results in a nonsense mutation at codon 12 (Gln
Stop). The right panel shows
the mutation in exon 3 (C
T at nucleotide 143) that results in a missense mutation at codon 48 (Pro
Leu). (B) AMPD1 sequence of
PCR-amplified genomic DNA. The upper panel shows the base substitution (C -* T at nucleotide 34) in exon 2. The lower panel shows the base
T at nucleotide 143) in exon
substitution (C
-.

-*

-*

-.

in the relevant regions of exon 2 and exon 3 (Fig. 4). The

AMPDJ genes for all three of these individuals contain both
cytosine and thymidine nucleotides at positions 34 and 143,
indicating they are heterozygotes.
Studies of Other Patients with AMPD Deficiency. Muscle
from 1 of the 10 other unrelated individuals with AMPD
deficiency was used to prepare cDNA as in the index case and
this cDNA was sequenced in its entirety. Genomic DNA
from all 11 AMPD-deficient subjects was sequenced in the
regions of exon 2 and 3. The only deviations from the control
sequence

are

-.

T transitions at

positions

34 and 143

(Table

2). The AMPD activity levels in skeletal muscle and the

symptoms in each of these individuals are listed in Table 1.
An immunoblot of muscle lysate from one of these individuals confirmed the absence of immunoreactive AMPD peptide in this patient.
Muscle was also available from one heterozygous individual and cDNA was prepared by reverse transcription PCR as
described above. Sequencing of individual subclones of the
PCR products prepared from this individual demonstrated
Ct Pt

that the C

-*

T transitions at

are

present

DISCUSSION
Eleven unrelated individuals with AMPD deficiency were
evaluated in this study, and both alleles of the AMPDJ gene
have the same two mutations in all 11 individuals-i.e., a C
-+

FIG. 3. Immunoreactive AMPD peptide in muscle lysate. Thirty

micrograms of protein from muscle lysate of a control (Ct) or the
index patient (Pt) was resolved on an 8% SDS polyacrylamide gel,
transferred to nitrocellulose paper, and incubated with polyclonal
antiserum raised to rat AMPD1 (5). This antiserum does not react
with other AMPD isoforms (5). The 86-kDa AMPD1 peptide in
control lysate is indicated.

34 and 143

--

AMPD --

positions

the same allele.

Population Studies. Genomic DNA obtained from 59 Caucasians, 13 African-Americans, and 106 Japanese was analyzed by two techniques for the nonsense mutation at position 34 (Fig. 5). PCR-amplified DNA from all subjects was
immobilized on Nytran filters and hybridized to a wild-type
or a mutant oligonucleotide for distinguishing the two types
of alleles (29). PCR-amplified DNA was also restricted with
Mae II in 31 subjects. This restriction enzyme recognizes the
sequence ACGT, found only once in this region of the normal
AMPD1 gene. The mutation at position 34 alters the sequence
of this restriction site, and the PCR product from the mutant
allele (AIGT) is not a substrate for this restriction endonuclease. Both tests give identical results in all cases. Seventeen
percent of Caucasians and 23% of African-Americans are
heterozygous for the nonsense mutation in exon 2, whereas
none of the Japanese examined have this mutant allele. In
addition, two Caucasians and one African-American were
found to be homozygous for this mutation. Each of these
individuals with the exon 2 nonsense mutation also has a C
T transition at position 143 of exon 3. Not one of the 34
chromosomes analyzed with a C at position 34 has a T at
position 143. Thus, in the 74 chromosomes examined, there
is no evidence for disconcordance between a C at positions
34 and 143 or a T at both of these positions.
on

T transition at

positions

34 and 143. The C

--

T transition

at position 34, in exon 2, results in a nonsense mutation that

predicts a severely truncated peptide as the product of this

mutant transcript. This truncated peptide terminates prior to
the synthesis of the catalytic domain of AMPD, providing an
explanation for the significant decrease of this enzyme activity in these individuals. Either this truncated peptide is not

6460

~\'l~ ~ ~I

Medical Sciences: Morisaki et al.

lF\(oll 2
I11. 1 RU()
i

It (.

Proc. Natl. Acad. Sci. USA 89 (1992)

1
34I
)II

t11I

I I *I 4

*1' 1'34 ( T3'e3 ( ('34A

d1.i)}.

I I IL ()
( ATC

()1t1g I

II

%,

*RId
|t~~~~~i.

aw
io'X'\

I~ ~ ~ ~ ~ t
l

Ofigo

\~ ~ ~ ~ ~ ~ ~.

i om i
oimtro
H
X iom
T1.34 (:1-34 (1:434

.
.

FAMILY G

FIG. 4. AMPD1 sequence in family members of index case.

(Upper) The sequence of PCR-amplified genomic DNA in the region
of exon 2 (nucleotide 34) is illustrated on the left and the sequence
in the region of exon 3 (nucleotide 143) is illustrated on the right.
Positions 34 and 143 both exhibit the presence of a C and T at these
sites, confirming this individual (the index patient's mother) is a
heterozygote. (Lower) The genotype of each family member is
depicted in this pedigree. The index patient is shown by the alrow.

recognized by the available antiserum or it is labile, explaining the absence of a discernible AMPD signal in immunoblots
performed with muscle extracts from these patients. Our
immunological observations in AMPD-deficient patients are
similar to those reported in prior studies by Fishbein (14) and
Sabina et al. (31). The variable residual AMPD activity found
in our patients is similar to that reported by other investigaTable 2. Population study

Nucleotide 143
Nucleotide 34
C
C
T (11)
T (11)
C (14)
C (47)
C/T (4)
C/T (10)
T (2)
T (1)
C (1)
African-American
C (9)
C/T (3)
C/T (3)
T (1)
T (1)
C (2)
C (106)
Japanese
The AMPD-deficient patients are described in Table 1. The DNA
samples from 59 Caucasians, 13 African-Americans, and 106 Japanese were obtained from normal volunteers or from investigators
who had no knowledge of the donors' medical history. The number
in parentheses is the number of individuals for whom the DNA
sequence was determined at the indicated nucleotide on PCR samples prepared from genomic DNA as described in the legend of Fig.
5. Every DNA sample was screened for a C or T at nucleotide 34
through allele-specific oligonucleotide hybridization and confirmed
by restriction digestion and/or direct sequencing. A limited number
of DNA samples were screened for a C or T at nucleotide 143 since
this required direct sequencing of the PCR product.

Group

Control
AMPD deficient
Caucasian

--

198 hp

1I 1)1)
hip

- 87

FIG. 5. Screening method for detecting the mutation at nucleotide 34. (A) Allele-specific oligonucleotides. PCR-amplified genomic
DNA from the region of exon 2 of AMPD1 was fixed to Nytran paper
and hybridized to a radiolabeled wild-type oligonucleotide (Oligo 1;
5'-ATACTCAC-jTTTCTCTTCAG-3') or a radiolabeled mutant oligonucleotide (Oligo 2; 5'-ATACTCACATTTCTCTTCAG-3'). DNA
from an individual homozygous for a C at nucleotide 34 (Homo C/C)
hybridizes only to oligonucleotide 1, DNA from an individual homozygous for a T at nucleotide 34 (Homo T/T) hybridizes only to
oligonucleotide 2, and DNA from a heterozygote (Hetero C/T)
hybridizes to both oligonucleotides. (B) Restriction endonuclease
mapping. PCR-amplified genomic DNA from the region of exon 2
was digested with Mae II. This enzyme recognizes the sequence
ACGT that occurs once in the wild-type PCR fragment, but it is
absent from the mutant PCR fragment as consequence of the C -. T
transition in exon 2. The undigested PCR fragment is 198 nucleotides
in length; the digested PCR fragments are 111 and 87 nucleotides in
length. Abbreviations for homozygote and heterozygote are the same
as in A. bp, Base pairs.

tors (14, 31). We assume as they do that most of this residual

activity reflects AMPD produced in nonmyocytes in the
muscle tissue by one of the other AMPD genes since this
activity is not reactive with antisera specific for the AMPD1
gene product (14, 31). However, we cannot exclude the
possibility that a small fraction of the residual activity is
produced in myocytes from the mutant AMPDJ gene as a
consequence of alternative splicing (see below).
The C -b T transition at nucleotide 143 in the AMPD1
transcript of these patients is apparently a silent mutation
based on studies performed with recombinant peptides produced in a prokaryotic expression system. Although detailed
kinetic studies have not been carried out with the wild-type
and mutant peptides, which differ by only a proline or a
leucine at codon 48, these two enzymes have comparable
activity under the assay conditions employed. The apparent
normal catalytic activity exhibited by the AMPD peptide
harboring a mutation in codon 48 could assume clinical
importance, if future studies demonstrate the human AMPD1
transcript is subject to alternative splicing, which deletes
exon 2. In rat, exon 2 is deleted from the majority of
transcripts produced from the AMPDJ gene in embryonic
muscle (32) and in response to changes in neural innervation
of skeletal muscle (unpublished observations). Since the
primary sequence of the AMPDJ gene has been highly
conserved in man and rat (23), a similar pattern of alternative
splicing may occur in embryonic human muscle or in response to external signals. Alternative splicing of exon 2 in
the human AMPD1 transcript would delete the nonsense
mutation specified by the C -* T transition at nucleotide 34.

Medical Sciences: Morisaki

et

Proc. Natl. Acad. Sci. USA 89 (1992)

al.

Although we have not detected alternative splicing in adult

human skeletal muscle (33), we cannot exclude at this time
the possibility that it may occur at an early stage of skeletal
muscle development, thereby ameliorating the consequences
of the nonsense mutation in exon 2.
The absence of a C -- T transition at nucleotide 143 in the
34 normal chromosomes examined makes it unlikely that this
mutation is a common polymorphism in these populations.
This fact, coupled with the 100%6 concordance of C -- T
transitions at nucleotides 34 and 143 in 40 chromosomes
analyzed from AMPD-deficient subjects and heterozygotes,
suggests one of two explanations. Either there is a significant
rate of spontaneous and coordinated mutation at both of
these positions or the doubly mutated allele is present at a
relatively high frequency in some populations. The latter
explanation seems more plausible since it is difficult to
envision a mechanism that results in spontaneous mutations
affecting the same two nucleotides in all of these alleles.
Furthermore, this mechanism would have to be restricted to
certain populations since the doubly mutated allele has not
been observed in the Japanese population. A more plausible
explanation in our opinion is that the doubly mutated allele
arose at some time in the remote past, and it has become
widely disseminated in individuals of Western European
descent. Studies are necessary to compare the frequency of
this mutant allele in different ethnic groups in Western
Europe, as well as African-Americans and native Africans, to
gain additional insight into the origin of this allele. The high
frequency of this allele in some populations may prove useful
in studying the relationship between different ethnic groups.
Recognizing that the frequency of AMPD heterozygosity is
-20% in Caucasians and African-Americans, it is not surprising that several centers have reported 1-3% of randomly
sampled muscle biopsies are deficient in this enzyme activity
(6, 7, 9, 12). Clearly 1-3% of individuals in these populations
do not have symptoms that are clinically severe enough to be
classified as a metabolic myopathy. Thus, the frequency of
this mutant allele in these populations raises a number of
questions about the clinical implications of this form of
AMPD deficiency. One could conclude this mutant allele is
a harmless polymorphism. On the other hand, this mutation
could be compensated for in some tissues or at some stages
of development by removal of exon 2 through alternative
splicing. The residual AMPD activity observed in muscle
tissue of these patients, presumably a product of another
member of this multigene family (3, 14, 31), might also
compensate for the mutation in the AMPDJ gene, especially
if this activity were present in myocytes. Other interpretations include the possibility that clinically significant myopathic symptoms develop only in individuals who have
another inherited or acquired abnormality in energy metabolism. Answers to these questions will require additional
physiological and molecular studies in controls and individuals with this mutant allele.
T.M., M.G., and H.M. contributed equally to this report. We
thank Dr. Ingrid Paetzke (Klinische Chemie Stddt Krankenhaus
Munchen-Schwabing), who kindly provided the results on AMPD
activity of the muscle biopsies of the 11 patients included in this
study, and Dr. Hisaichi Fujii (Tokyo Women's Medical College),
who generously supplied the DNA samples for the Japanese subjects.
This work was supported by grants to E.W.H. (DK-12413, National
Institutes of Health) and M.G. (Deutsche Forschungsgemeinschaft).
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