Journal of Clinical & Experimental Neuroimmunology
Open Access

Facioscapulohumeral Muscular Dystrophy (FSHD) is one of the most common forms of muscular dystrophy, with an estimated prevalence of 1 in 20,000. FSHD is characterized by progressive weakness of the facial, shoulder, and upper arm muscles, followed by involvement of the lower extremities. This autosomal dominant disorder is genetically heterogeneous, with two major subtypes: FSHD1 and FSHD2. Molecular diagnosis has evolved considerably in recent years, offering new insights into its pathophysiology and providing important tools for clinicians and genetic counselors. This review outlines the current advances in the molecular diagnosis of FSHD, discusses their clinical implications, and highlights the role of genetic counseling in patient care.

Genetic Basis of FSHD

FSHD is caused by the aberrant expression of the DUX4 gene, a double homeobox transcription factor that is normally silenced in healthy muscle tissue. The expression of DUX4 leads to a toxic cascade that damages muscle cells, ultimately resulting in the characteristic muscle weakness observed in FSHD.

FSHD1: Chromosome 4q35 contractions

Approximately 95% of patients with FSHD have FSHD1, which is linked to a contraction of the D4Z4 macrosatellite repeat array on chromosome 4q35. Healthy individuals have between 11 to 100 D4Z4 repeat units, while patients with FSHD1 typically have 1 to 10 repeat units [1]. This reduction in the number of D4Z4 repeats allows for the inappropriate activation of the DUX4 gene in muscle cells, contributing to disease progression.

The contraction of the D4Z4 repeat in FSHD1 patients occurs on a specific chromosomal background known as 4qA haplotype, which contains a functional polyadenylation signal at the distal end of the DUX4 gene. This signal is essential for stabilizing the DUX4 mRNA, allowing its expression to contribute to muscle pathology.

FSHD2: Epigenetic dysregulation

FSHD2 accounts for about 5% of cases and is characterized by mutations in genes that regulate chromatin structure and function, most commonly the SMCHD1 gene (Structural Maintenance of Chromosomes Hinge Domain 1). In FSHD2, patients do not have the D4Z4 contraction seen in FSHD1, but they do have epigenetic changes that lead to hypomethylation of the D4Z4 region. This hypomethylation allows for aberrant activation of DUX4 in a manner similar to FSHD1 [2].

Interestingly, patients with FSHD2 also require the presence of the 4qA haplotype, similar to FSHD1, in order for DUX4 expression to occur. Therefore, while the mechanisms of D4Z4 repeat contraction and epigenetic dysregulation differ, both ultimately result in the same pathogenic process involving DUX4 activation.

Molecular diagnostic techniques

The molecular diagnosis of FSHD involves identifying the D4Z4 repeat contraction in FSHD1 or the epigenetic changes associated with FSHD2. Advances in molecular genetics have refined the diagnostic process, increasing its accuracy and accessibility.

1. Southern Blot Analysis

Southern blotting has historically been the gold standard for diagnosing FSHD1 by determining the size of the D4Z4 repeat array. This technique allows for the detection of the reduced number of D4Z4 repeats on chromosome 4q35, confirming a diagnosis of FSHD1.

Despite its reliability, Southern blot analysis has limitations, including being labor-intensive, time-consuming, and requiring a significant amount of DNA. Consequently, more efficient molecular techniques have been developed in recent years.

2. Polymerase chain reaction (PCR)-based methods

The advent of PCR-based methods has allowed for faster and more precise molecular diagnosis of FSHD. Techniques such as short tandem repeat (STR) analysis and long-range PCR have been developed to assess the number of D4Z4 repeats [3]. These methods are less labor-intensive and more scalable than Southern blotting, making them a preferred option in many clinical settings.

3. Next-generation sequencing (NGS)

NGS has revolutionized the molecular diagnosis of many genetic disorders, including FSHD. While it is not typically used for routine FSHD1 diagnosis due to the complexity of the D4Z4 repeat region, NGS is invaluable in diagnosing FSHD2. By sequencing genes involved in chromatin regulation, such as SMCHD1, NGS allows for the identification of mutations that lead to FSHD2. Additionally, NGS can be used to identify novel mutations or epigenetic regulators involved in FSHD.

4. Methylation analysis

DNA methylation analysis is particularly important for diagnosing FSHD2. In FSHD2 patients, the D4Z4 region is hypomethylated due to mutations in chromatin regulatory genes like SMCHD1. Methylation-sensitive techniques such as bisulfite sequencing or methylation-specific PCR can be used to assess the methylation status of the D4Z4 region, helping to confirm a diagnosis of FSHD2 [4].

Genetic counseling in FSHD

Given the genetic complexity of FSHD, genetic counseling is a critical component of patient care. Genetic counselors provide essential support in helping patients understand their diagnosis, the inheritance patterns of FSHD, and the implications for family planning.

1. Inheritance patterns

FSHD is inherited in an autosomal dominant manner, meaning that an affected individual has a 50% chance of passing the mutation to their offspring. However, the severity of the disease can vary even within families, with some individuals exhibiting mild symptoms and others developing more severe muscle weakness. Genetic counselors play a key role in explaining the variability of disease expression and the genetic risks to family members.

2. Predictive testing

For individuals with a family history of FSHD, predictive genetic testing can help identify whether they carry the genetic mutation before the onset of symptoms. This information can be particularly important for family planning decisions. However, genetic counseling should precede testing to ensure that patients understand the implications of a positive or negative result, as well as the potential psychological impact.

3. Prenatal and preimplantation genetic diagnosis

Advances in reproductive technology have made it possible for individuals with FSHD to pursue options such as preimplantation genetic diagnosis (PGD) or prenatal testing. PGD allows for the selection of embryos free from the genetic mutation, while prenatal testing can confirm whether a fetus has inherited the mutation [5]. Genetic counseling is essential in these situations, as it helps prospective parents navigate complex ethical and emotional considerations.

4. Psychosocial support

A diagnosis of FSHD can be life-changing, not only for the affected individual but also for their family members. Genetic counselors provide emotional support and resources to help patients cope with the challenges of living with a chronic, progressive disorder. Counseling may also involve coordinating care with other healthcare providers, such as neurologists, physical therapists, and psychologists.

Clinical implications of molecular diagnosis

The accurate molecular diagnosis of FSHD is critical for guiding clinical management. Early diagnosis allows for timely intervention, which may include physical therapy, orthopedic management, and monitoring for potential complications such as respiratory insufficiency or hearing loss. Furthermore, molecular diagnosis provides a foundation for future therapeutic developments aimed at targeting the underlying genetic mechanisms of FSHD.

Additionally, understanding the molecular basis of FSHD has significant implications for the development of gene-based therapies. Researchers are investigating strategies to reduce or block the expression of DUX4, which could slow or halt the progression of the disease. Patients with a confirmed molecular diagnosis may be eligible for participation in clinical trials testing these new treatments [6-8].

Conclusion

Facioscapulohumeral Muscular Dystrophy is a genetically complex disorder with two primary subtypes: FSHD1, caused by D4Z4 repeat contraction, and FSHD2, resulting from epigenetic dysregulation. Molecular diagnostic techniques have evolved to provide more accurate and accessible diagnosis, enabling better clinical care and personalized treatment strategies. Genetic counseling plays an essential role in helping patients and families understand the genetic aspects of FSHD, guiding family planning decisions, and providing psychosocial support. As research advances and novel therapies are developed, molecular diagnosis and genetic counseling will remain at the forefront of FSHD management, improving patient outcomes and quality of life.

References

1. Jogn HJ, Paul GA (2010)Ocular Inflammatory Disease and Uveitis Manuel: Diagnosis and Treatment, 1st Ed. Lippincott Williams & Wilkins.
2. Read RW, Holland GN, Rao NA, Tabbara KF, Ohno S, et al. (2001)Revised diagnostic criteria for Vogt-Koyanagi-Harada disease: report of an international committee on nomenclature. Am J Ophthalmol 131(5): 647-652.

Indexed at, Google Scholar, Crossref

3. Attia S, Khochtali S, Kahloun R, Zaouali S, Khairallah M (2012)Vogt – Koyanagi – Harada disease. Expert Rev. Ophthalmol 7(6): 565-585.

Indexed at, Google Scholar, Crossref

4. Moorthy RS, Inomata H, Rao NA (1995)Major Review - Vogt-Koyanagi-Harada Syndrome. Surv Ophthalmol 39(4): 265-292.

Indexed at, Google Scholar, Crossref

5. Snyder DA, Tessler HA (1980) Vogt-Koyanagi-Harada syndrome. Am J Ophthalmol 90: 69-75.

Google Scholar

6. Agarwal A (2008)Fundus Fluorescein and Indocyanine Green Angiography: A textbook and Atlas. Slack Inc.

Google Scholar

7. Chee SP, Jap A, Cheung CMG (2010)The Prognostic Value of Angiography in Vogt-Koyanagi-Harada Disease. Am J Ophthalmol 150(6): 888- 893.

Indexed at, Google Scholar, Crossref

8. Morita S, Nakamaru Y, Obara N, Masuya M, Fukuda S (2014)Characteristics and prognosis of hearing loss associated with Vogt-Koyanagi-Harada disease. Audiol Neurootol 19(1): 49-56.

Indexed at, Google Scholar, Crossref