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Clinical and Genetic Heterogeneity in Progressive External Ophthalmoplegia Due to Mutations in Polymerase 
Massimiliano Filosto, MD;
Michelangelo Mancuso, MD;
Yutaka Nishigaki, MD;
Jacklyn Pancrudo, BS;
Yadollah Harati, MD;
Clifton Gooch, MD;
Ami Mankodi, MD;
Lydia Bayne, MD;
Eduardo Bonilla, MD;
Sara Shanske, PhD;
Michio Hirano, MD;
Salvatore DiMauro, MD
Arch Neurol. 2003;60:1279-1284.
Background The mendelian forms of progressive external ophthalmoplegia (PEO) associated with multiple mitochondrial DNA deletions are clinically heterogeneous disorders transmitted as dominant or recessive traits. Autosomal dominant PEO is caused by mutations in at least 3 genes: adenine nucleotide translocator-1 (ANT1), encoding the muscle-specific adenine nucleotide translocator; chromosome 10 open reading frame 2 (C10orf2), encoding Twinkle helicase; and polymerase  (POLG), encoding the  subunit of polymerase . Mutations in POLG can also cause autosomal recessive PEO, which is often associated with multisystemic disorders.
Objective and Methods To further investigate the frequency and genotype-phenotype correlations of mutations in the POLG gene, we used single-stranded conformational polymorphism analysis and direct sequencing to screen 30 patients with familial or sporadic PEO and multiple mitochondrial DNA deletions in muscle but without mutations in ANT1 and C10orf2.
Results Four unrelated patients had novel POLG mutations. A woman with PEO and mental retardation had a heterozygous Gly1076Val mutation. Two patients, one with PEO, exercise intolerance, and gastrointestinal dysmotility and the other with PEO, neuropathy, deafness, and hypogonadism, both had a Pro587Leu change. The fourth patient, who was compound heterozygous for Ala889Thr and Arg579Trp mutations, had PEO, gastrointestinal dysmotility, and neuropathy. These mutations were not detected in 120 healthy control alleles.
Conclusions Our results demonstrate that POLG mutations account for a substantial proportion of patients (13%) with PEO and multiple mitochondrial DNA deletions and cause both clinically and genetically heterogeneous disorders.
From the Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY (Drs Filosto, Mancuso, Nishigaki, Gooch, Bonilla, Shanske, Hirano, and DiMauro and Ms Pancrudo); Baylor College of Medicine, Houston, Tex (Dr Harati); School of Medicine and Dentistry, University of Rochester, Rochester, NY (Dr Mankodi); and Good Samaritan Clinic, Portland, Ore (Dr Bayne).
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