Ataxia neuropathy spectrum is part of a group of conditions called the POLG-related disorders. The conditions in this group feature a range of similar signs and symptoms involving muscle-, nerve-, and brain-related functions. Ataxia neuropathy spectrum now includes the conditions previously called mitochondrial recessive ataxia syndrome (MIRAS) and sensory ataxia neuropathy dysarthria and ophthalmoplegia (SANDO).

As the name implies, people with ataxia neuropathy spectrum typically have problems with coordination and balance (ataxia) and disturbances in nerve function (neuropathy). The neuropathy can be classified as sensory, motor, or a combination of the two (mixed). Sensory neuropathy causes numbness, tingling, or pain in the arms and legs, and motor neuropathy refers to disturbance in the nerves used for muscle movement.

Most people with ataxia neuropathy spectrum also have severe brain dysfunction (encephalopathy) and seizures. Some affected individuals have weakness of the external muscles of the eye (ophthalmoplegia), which leads to drooping eyelids (ptosis). Other signs and symptoms can include involuntary muscle twitches (myoclonus), liver disease, depression, migraine headaches, or blindness.

Ataxia neuropathy spectrum is caused by mutations in the POLG gene or, rarely, the TWNK gene.

The POLG gene provides instructions for making one part, the alpha subunit, of a protein called polymerase gamma (pol γ). The TWNK gene provides instructions for making a protein called Twinkle. Pol γ and Twinkle function in mitochondria, which are structures within cells that use oxygen to convert the energy from food into a form cells can use. Mitochondria each contain a small amount of DNA, known as mitochondrial DNA (mtDNA), which is essential for the normal function of these structures. Pol γ and Twinkle are both integral to the process of DNA replication by which new copies of mtDNA are produced.

Mutated pol γ or mutated Twinkle reduce mtDNA replication. Although the mechanisms are unknown, mutations in the POLG gene often result in fewer copies of mtDNA (mtDNA depletion), and mutations in the TWNK gene often result in deletions of large regions of mtDNA (mtDNA deletion). MtDNA depletion or deletion occurs most commonly in muscle, brain, or liver cells. MtDNA depletion causes a decrease in cellular energy, which could account for the signs and symptoms of ataxia neuropathy spectrum. It is unclear what role mtDNA deletions play in the signs and symptoms of the condition.

Normal Function

The POLG gene provides instructions for making the active piece, called the alpha subunit, of a protein called polymerase gamma (pol γ). To be most effective, the alpha subunit attaches to two copies of another protein called the beta subunit to form pol γ. Pol γ is a DNA polymerase, which is a type of enzyme that "reads" sequences of DNA and uses them as templates to produce new DNA. These enzymes are important for copying (replicating) cells' genetic material. DNA polymerases also play critical roles in DNA repair.

Pol γ functions in mitochondria. Mitochondria are structures within cells in which a process called oxidative phosphorylation converts the energy from food into a form that cells can use. Mitochondria each contain a small amount of DNA, known as mitochondrial DNA (mtDNA), which is essential for the normal function of these structures. Pol γ is the only DNA polymerase that is active in mitochondria and that can replicate mtDNA.

Health Conditions Related to Genetic Changes

Alpers-Huttenlocher syndrome

There are many variants (also called mutations) in the POLG gene that cause Alpers-Huttenlocher syndrome. Alpers-Huttenlocher syndrome is part of a group of conditions called POLG-related disorders that have overlapping signs and symptoms affecting muscle-, nerve-, and brain-related functions. Alpers-Huttenlocher syndrome is characterized by seizures, loss of mental and movement abilities (psychomotor regression), and liver disease. The liver disease in Alpers-Huttenlocher syndrome can be brought on or made worse by valproic acid, a common treatment for seizures.

Most POLG gene variants change single protein building blocks (amino acids) in the alpha subunit of pol γ. The variants can have several effects on the function of pol γ. The alpha subunit may lose the ability to attach to the beta subunits to form pol γ. Alternately, altered pol γ may be unable to bind the existing mtDNA strand to use as a template. Or, it may have a reduced ability to attract the DNA building blocks (nucleotides) that it uses to form new DNA. These effects impair DNA synthesis and may lead to insertion of the wrong nucleotide and decreased ability to fix the error.

The most common POLG gene variant in Alpers-Huttenlocher syndrome replaces the amino acid alanine with the amino acid threonine at position 467 (written as Ala467Thr or A467T). This variant blocks the ability of the alpha subunit to attach to the beta subunits and reduces pol γ's ability to synthesize DNA. The Ala467Thr variant is also common in other POLG-related disorders. The different conditions may be determined, in part, by the variant in the other copy of POLG, but there are still some variant combinations that can cause more than one of the disorders. It is unclear how the same variant can lead to different conditions.

Although the mechanism is unknown, many people with Alpers-Huttenlocher syndrome have fewer copies of mtDNA (mtDNA depletion). This abnormality is seen only in the tissues affected by the disease. MtDNA depletion leads to impaired oxidative phosphorylation and a decrease in cellular energy. These impairments affect tissues whose cells do not divide continually, such as brain, muscle, and liver. These tissues are most affected because they are more dependent on oxidative phosphorylation for energy, and impaired cells in these tissues are not generally replaced by new cells. The lack of energy supplies in these tissues could account for the signs and symptoms of Alpers-Huttenlocher syndrome.

Ataxia neuropathy spectrum

Another condition caused by variants in the POLG gene is ataxia neuropathy spectrum, a POLG-related disorder that is characterized by problems with coordination and balance (ataxia) and disturbances in nerve function (neuropathy). The conditions previously named mitochondrial recessive ataxia syndrome (MIRAS) and sensory ataxia neuropathy dysarthria and ophthalmoplegia (SANDO) are now included in the ataxia neuropathy spectrum.

As mentioned above, most variants in the POLG gene change single amino acids in the alpha subunit of pol γ, and these variants can have several effects on the function of pol γ. As a result, pol γ has a reduced ability to replicate mtDNA. The most common POLG gene variant in ataxia neuropathy spectrum is the same as that in Alpers-Huttenlocher syndrome (described above), Ala467Thr. It is unclear how the same variant can lead to different disorders.

As in other POLG-related disorders, people with ataxia neuropathy spectrum typically have mtDNA depletion in the tissues affected by the condition, such as the brain. MtDNA depletion decreases the amount of energy available to the cell due to reduced oxidative phosphorylation, which may account for the signs and symptoms of ataxia neuropathy spectrum.

Childhood myocerebrohepatopathy spectrum

Childhood myocerebrohepatopathy syndrome (MCHS) is also caused by variants in the POLG gene. MCHS is a POLG-related disorder that affects the muscles (myo-), brain (cerebro-), and liver (hepato-).

Many variants in the POLG gene can cause MCHS. Most of these variants change single amino acids in the alpha subunit of pol γ. These variants reduce the activity of pol γ, decreasing mtDNA replication.

As in other POLG-related disorders, people with MCHS typically have mtDNA depletion in muscle, brain, or liver tissue. MtDNA depletion impairs oxidative phosphorylation in these tissues and decreases the energy available to the cells, which may cause the signs and symptoms of MCHS.

Mitochondrial neurogastrointestinal encephalopathy disease

MedlinePlus Genetics provides information about Mitochondrial neurogastrointestinal encephalopathy disease

Myoclonic epilepsy myopathy sensory ataxia

Variants in the POLG gene cause another POLG-related disorder called myoclonic epilepsy myopathy sensory ataxia (MEMSA), which is characterized by recurrent seizures (epilepsy), muscle weakness (myopathy), and problems with coordination and balance (ataxia).

Most of the POLG gene variants involved in MEMSA change single amino acids in the alpha subunit of pol γ. These variants result in a less active form of pol γ that has a reduced ability to replicate mtDNA.

As in other POLG-related disorders, people with MEMSA typically have mtDNA depletion in affected tissues, such as muscle or brain. MtDNA depletion leads to impaired oxidative phosphorylation and decreased energy reserves in affected tissues, which may cause the signs and symptoms of MEMSA.

Progressive external ophthalmoplegia

Variants in the POLG gene are frequently responsible for an eye condition called progressive external ophthalmoplegia, another POLG-related disorder. This condition weakens the muscles that control eye movement and causes the eyelids to droop (ptosis).

There are at least 67 POLG gene variants that cause progressive external ophthalmoplegia. Most POLG gene variants change single amino acids in the alpha subunit of pol γ, which decreases the efficiency of mtDNA replication. As in another POLG-related disorder, Alpers-Huttenlocher syndrome (described above), the most common POLG gene variant in progressive external ophthalmoplegia is Ala467Thr. It is unclear how the same variants can lead to different disorders.

In progressive external ophthalmoplegia, variants in the POLG gene result in large deletions of genetic material from mtDNA in muscle tissue, rather than the overall mtDNA depletion seen in other POLG-related disorders. The reason for this difference is unknown. Researchers have not determined how deletions of mtDNA lead to the specific signs and symptoms of progressive external ophthalmoplegia, although the features of the condition are probably related to impaired oxidative phosphorylation. It has been suggested that eye muscles are commonly affected by mitochondrial defects because they are especially dependent on oxidative phosphorylation for energy.

Leigh syndrome

MedlinePlus Genetics provides information about Leigh syndrome

Other Names for This Gene

• DNA polymerase subunit gamma-1
• mitochondrial DNA polymerase catalytic subunit
• PolG, catalytic subunit
• PolG-alpha
• POLG1
• POLGA
• polymerase (DNA directed), gamma
• polymerase (DNA) gamma, catalytic subunit

Genomic Location

Ataxia neuropathy spectrum can have different inheritance patterns depending on the associated gene.

Mutations in the POLG gene cause a form of the condition that is inherited in an autosomal recessive pattern, which means both copies of the gene in each cell have mutations. The parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but they typically do not show signs and symptoms of the condition.

Mutations in the TWNK gene cause a form of the condition that is inherited in an autosomal dominant pattern, which means one copy of the altered gene in each cell is sufficient to cause the disorder.

The prevalence of ataxia neuropathy spectrum is unknown.