Signs and symptoms
The symptoms of CMT often appear in childhood and adolescence, but in some cases, they may not develop until adulthood. The severity and progression of symptoms can vary widely between individuals even among members of the same family. Some people do not experience symptoms until their early 30s or 40s. The most common early sign of CMT is difficulty walking, often due to weakness in the muscles of the lower legs and feet. This muscle weakness can lead to foot drop, where patients have trouble lifting the front part of the foot, causing them to trip or adopt a high-stepping gait. Over time, individuals may develop distinctive foot deformities, such as high arches (known as pes cavus) and curled toes (hammertoes), due to muscle imbalance. As the disease progresses, the weakness often spreads to the hands and forearms, making tasks that require fine motor skills—like buttoning a shirt or writing—more difficult. In addition to motor symptoms, many people with CMT also experience a gradual loss of sensation in the feet, legs, hands, and arms. This sensory loss may affect the ability to feel pain, temperature, or touch, and can lead to problems with balance, especially in low-light conditions. Symptoms and progression of the disease can vary. Involuntary grinding of teeth and squinting are prevalent and often go unnoticed by the person affected. Breathing can be affected in some, as can hearing, vision, and neck and shoulder muscles.Causes and Genetics
Classification
Charcot–Marie–Tooth (CMT) disease is a genetically heterogeneous disorder, meaning that it can be caused by mutations in many different genes. To date, dozens of genes have been linked to various forms of CMT, reflecting the complexity of its molecular basis. As a result, CMT is classified into several major types, such as CMT1, CMT2, CMT4, CMTX, and intermediate forms, based on the pattern of inheritance and whether the primary defect affects the myelin sheath or the axon. CMT1 involves demyelination and is most caused by duplication of the PMP22 gene, while CMT2 is primarily axonal and frequently linked to mutations in genes such as MFN2 or NEFL. X-linked and autosomal recessive forms, like CMTX and CMT4, are also recognized and often associated with more severe or early-onset symptoms. Each type is further divided into subtypes, defined by the specific gene that is mutated. This genetic classification helps guide diagnosis, prognosis, and, potentially, the development of targeted therapiesGARS1-related axonal neuropathy (CMT2)
Charcot–Marie–Tooth type 2 (CMT2) is commonly classified as an axonal neuropathy due to the degeneration of nerve axons observed in affected individuals. Unlike CMT type 1, which results from damage to the myelin sheath, CMT type 2 is characterized by direct injury to the axon itself.. This axonal damage can disrupt nerve signal transmission between the brain and muscles, resulting in symptoms such as muscle weakness, atrophy, reduced sensation, and foot deformities. The onset of symptoms in CMT2 typically occurs between the ages of 5 and 25. CMT2D is one of more than 31 recognized subtypes of Charcot–Marie–Tooth disease type 2 (CMT2) and is diagnosed when both motor and sensory deficits are present—such as loss of sensation caused by degeneration of sensory axons. In cases where only motor symptoms are observed without sensory involvement, the condition is classified as distal hereditary motor neuropathy type V (dHMN-V). The reason behind the variability in sensory involvement among patients with GARS1-related neuropathy remains unclear. Symptoms of CMT2D typically include muscle weakness, loss of sensation, reduced reflexes, and muscle atrophy, which are similar to those seen in both CMT1 and other CMT2 variants. The severity and combination of symptoms vary widely among patients, particularly regarding the extent of sensory involvement. CMT2D is a result of autosomal dominant mutations in the human ''GARS''1 gene located at 7p14.3 and is thought to be caused by aberrant gain-of-function missense mutations. The GARS1 gene encodes the enzyme glycyl-tRNA synthetase (GlyRS), which belongs to the class II group of aminoacyl-tRNA synthetases. This enzyme is essential in the process of protein synthesis, facilitating the bonding of the amino acid glycine to its corresponding transfer RNA (tRNA). Through this process, GlyRS ensures the accurate incorporation of glycine during translation, making it essential for proper protein production. Many different mutations have been found in CMT2D patients, and how mutations in GARS1 cause CMT2D remains unclear. However, mutant glycyl-tRNA synthetase (GlyRS) is thought to interfere with transmembrane receptors, causing motor disease, and that mutations in the gene could disrupt the ability of GlyRS to interact with its cognate RNA, disrupting protein production. The ''GARS1'' mutations present in CMT2D cause a deficient amount of glycyl-tRNA in cells, preventing the elongation phase of protein synthesis. Elongation is a key step in protein production, so when a deficiency of glycyl-tRNA exists, protein synthesis is unable to continue at glycine sites. ''GARS1'' mutations also stall initiation of translation due to a stress response that is induced by glycine addition failure. By stalling elongation and initiation of translation, CMT2D mutations in ''GARS1'' cause translational repression, meaning that overall translation is inhibited. GARS1-associated axonal neuropathy is a progressive condition that deteriorates over time. Although the precise mechanisms driving the chronic neurodegeneration caused by mutant glycyl-tRNA synthetase (GlyRS) remain unclear, one proposed theory involves disrupted vascular endothelial growth factor (VEGF) signaling. The mutant GlyRS aberrantly interacts with neuronal transmembrane receptors, such as neuropilin 1 (Nrp1) and VEGF receptors, interfering with normal signaling pathways and contributing to the development of neuropathy. GARS-CMT2D mutations alter GlyRS and allow it to bind to the Nrp1 receptor, interfering with the normal binding of Nrp1 to VEGF. While enhanced expression of VEGF improves motor function, reduced expression of Nrp1 worsens CMT2D; because Nrp1 binds to mutant GlyRS in mutant GARS1-CMT2D individuals, Nrp1 expression is reduced, in turn worsening motor function. Mice with deficient VEGF demonstrate motor neuron disease over time. Thus, the VEGF/Nrp1 pathway is considered to be targetable for CMT2D treatment.X-linked CMT
Main article: X-linked Charcot–Marie–Tooth disease CMT can also be produced by X-linked mutations, in which case it is called X-linked CMT (CMTX). In CMTX, mutated connexons create nonfunctional gap junctions that interrupt molecular exchange and signal transport.The mutation can appear in the '' GJB1'' gene coding for the connexin 32 protein, a gap junction protein expressed in Schwann cells. Because this protein is also present in oligodendrocytes, demyelination can appear in the CNS as well.Diagnosis
Charcot–Marie–Tooth (CMT) disease can be diagnosed using a combination of three primary methods: nerve conduction studies, nerve biopsy, and genetic testing. Nerve conduction studies assess the velocity of electrical impulses traveling through nerves, whereas nerve biopsy entails the examination of small samples of nerve tissue. Genetic testing can conclusively diagnose CMT by identifying specific mutations linked to the condition. however, but not all the genetic markers for CMT are known. Initial signs of CMT often include lower leg weakness, such as foot drop, and foot deformities like high arches or hammertoes. However, these symptoms alone do not provide enough information for a diagnosis. Individuals showing signs of CMT should be referred to a neurologist or rehabilitation medicine specialist for further evaluation and treatment.During a physical examination, the physician may assess muscle strength such as asking the patient to walk on their heels or resist applied pressure on their legs and check for sensory loss and reduced deep-tendon reflexes, such as the knee-jerk response. A detailed family history is also important, as CMT is an inherited condition. While the absence of a family history does not rule out CMT, it can help the physician distinguish it from other causes of neuropathy, such as diabetes, toxin exposure, or certain medications.Treatment and Management
History
Charcot-Marie-Tooth disease was first discovered in 1886 by three scientists: Jean-Martin Charcot (1825–1893) and his assistant Pierre Marie (1853–1940), along with the English doctor Howard Henry Tooth (1856–1925). In their original publication, titled “Concerning a Special Form of Progressive Muscular Atrophy,” Charcot and Marie acknowledged that similar cases had been previously published in medical literature Their findings described hereditary neuropathy, marked by gradual muscle wasting and diminished sensation in the extremities.This crucial discovery helped establish CMT as a distinct clinical entity, differentiating it from other neuromuscular conditions such as muscular dystrophies. Over the years, advancements in neurogenetics have led to the identification of various genetic mutations responsible for the disease, significantly enhancing our understanding of its pathogenesis and classification. Charcot also noted that prior descriptions of the disease were neither objective nor thorough. Most of the earlier accounts merely mentioned that CMT was hereditary. As a result, Charcot felt it was essential to provide a comprehensive description of the disease, ensuring that it received the attention it deserved. In 2010, Charcot–Marie–Tooth (CMT) disease became one of the first conditions in which the precise genetic cause was identified in an individual patient using whole-genome sequencing. This groundbreaking discovery was made by scientists affiliated with thSee also
* Charcot–Marie–Tooth disease classifications * Palmoplantar keratoderma and spastic paraplegia * Hereditary motor and sensory neuropathies * Hereditary motor neuropathies * Low copy repeats * '' Christina's World''References
External links
* {{DEFAULTSORT:Charcot-Marie-Tooth Disease Peripheral nervous system disorders Cytoskeletal defects Syndromes affecting the nervous system Diseases named after discoverers