CASE REPORT
Corresponding Author: E. Karaoz
Department of Histology and Embryology, Faculty of Medicine, Istinye University, Istanbul, Turkey
Tel: +902129998099, Fax: +728188291209, E-mail address: ekaraoz@hotmail.com
Copyright © 2022 Tehran University of Medical Sciences. Published by Tehran University of Medical Sciences This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited
A Case of Non-Progressive Congenital Myopathy: Efficacy and Clinical
Outcomes of the Wharton's Jelly Derived Mesenchymal Stem Cell
Transplantation
Riza Azeri1,2, Eda Sun3,4, Erdal Karaoz3,4,5
1 Department of Physical Therapy and Rehabilitation, Liv Hospital, Istanbul, Turkey
2 Department of Physiotherapy and Rehabilitation, Faculty of Health Science, Istinye University, Istanbul, Turkey
3 Department of Histology and Embryology, Faculty of Medicine, Istinye University, Istanbul, Turkey
4 Center for Stem Cell and Tissue Engineering Research and Practice, Istinye University, Istanbul, Turkey
5 Center for Regenerative Medicine and Stem Cell Research and Manufacturing, Liv Hospital, Istanbul, Turkey
Received: 12 Aug. 2021; Accepted: 14 Mar. 2022
Abstract- Non-Progressive Congenital Myopathy is a disease characterized by muscle weakness, and
unfortunately, there is no conventional treatment. In the last decade, regenerative medicine practices have
become a rising value, and Mesenchymal Stem Cells (MSCs) have fascinating outcomes in regenerative
medicine with their high regenerative capacities, their ability to regulate with paracrine secretions, and their
immunological properties. Based on our experience in our previous clinical studies, Wharton's-Jelly-derived
(WJ-)MSCs are the most suitable source for muscle diseases among all MSC sources. In this study, we
evaluated the outcomes of 10 doses of WJ-MSC transplantation to the patient diagnosed with Non-Progressive
Congenital Myopathy. A 17-year-old female with a SPEN-1 mutation, Non-Progressive Congenital Myopathy
patient received 10 times as 1×10⁶ /kg in the intra-arterial, intramuscular and intravenous administration of
allogenic WJ-MSC. Before and after the treatment, the patient was followed-up with the upper extremity scale,
Vignos lower extremity scale, muscle strength scale, functional independence measure, and evaluation of
Serum creatine kinase (CK) levels. Improvement in both upper extremity scale and Vignos lower extremity
scales, increasing in muscle strength, and decreasing in CK-level were detected. Although transplantation of
WJ-MSC cannot treat any genetic-based diseases, they may benefit in alleviating clinical outcomes of disease.
More importantly, WJ-MSC transplantation may offer a better quality of life by alleviating the symptoms of
this rare disease with no treatment option that can be provided in conventional methods.
© 2022 Tehran University of Medical Sciences. All rights reserved.
Acta Med Iran 2022;60(4):249-253.
Keywords: Non-progressive congenital myopathy; Mesenchymal stem cells; Muscle fibrosis; Muscle-fiber
regeneration
Introduction
Non-progressive-congenital-myopathy is a muscular
disorder characterized by hypotonia, motor development
retardation, and proximal muscle weakness without any
conventional treatment. Pathophysiology of congenital
myopathy is related to protein defects that play a
significant role in skeletal muscle contraction via their
interaction with myosin, calcium homeostasis of skeletal
muscle, or sarcomere proteins in skeletal muscle (1).
Mesenchymal stem cells (MSC) are emerging
biological sources used in regenerative medicine with
their capacity for self-renewal, differentiation potential,
anti-inflammatory, antiapoptotic, regenerative, and
immunomodulatory abilities, and the preferable cellular
source for therapeutic applications (2). MSC can be
derived from different sources (3); Wharton-jelly-derived
MSC(WJ-MSCs) are promising therapeutic sources for
Wharton's jelly derived mesenchymal stem cell transplantation to a non-progressive congenital myopathy
250 Acta Medica Iranica, Vol. 60, No. 4 (2022)
the treatment of myopathies by preventing muscle cell
death via repressing apoptosis (3) with their paracrine
activity such as secreting cytokines, releasing exosomes,
and reaching the damaged host cells and by repopulating
promote muscle regeneration and so improved muscle
function and pathology (4).
The cellular therapy for non-progressive congenital
myopathy using allogenic MSCs underlies the
improvement of myogenic differentiation (5) reverses
myopathy via increasing the satellite cell pool. This
clinical study aimed to consider the efficacy of allogeneic
WJ-MSC treatment for the rare disease of non-
progressive-congenital-myopathy.
Case Report
A 17-year-old female patient got diagnosed with non-
progressive-congenital-myopathy with a muscle biopsy
at the age of 10 was treated. Histological sections showed
a slight diameter difference between muscle fibers,
atrophy, several regenerated fibers, and rare central nuclei
fibers. There was a significant increase in the prismatic
adipose tissue and a focal increase in the endomysial
connective tissue. Spectrin, merosin, dystrophin (1,2,3),
alpha, beta.
üçç, gamma, and delta sarcoglycan were positive in
immunohistochemistry staining also confirmed
myopathic changes.
This patient had a homozygous deletion in the 6th exon
of the SPEN1 gene, and her healthy mother-father-brother
was heterozygous for the same deletion. The study was
approved by the Ethical Committee of the Ministry of
Health Republic of Turkey (protocol
number:56733164/203), was performed in accordance
with the Helsinki Declaration, and informed consent was
received from the patient’s family.
The patient was treated with allogeneic WJ-MSC with
a total of ten doses with four additional doses as 1×106/kg
once a month. The treatment was initially planned as 6
doses. The three doses (1st,4th, and 6th) were planned the
combination of intra-arterial, intra-muscular, and intra-
venous; the other three doses (2nd,3rd, and 5th) of
intramuscular injections of WJ-MSC into abdominal
muscles, deltoid, quadriceps, tibialis anterior and gluteal
muscles by using ultrasonography (Figure 1). Nine
months after 6 doses of planned therapy, an increase in
Creatine Kinase (CK) level was detected. So, we decided
to add additional 4 doses of WJ-MSc transplantations by
following the first treatment protocol design.
Figure 1. Designing and timeline of stem cell transplant therapy for Non-Progressive Congenital Myopathy patient
Transplanted MSCs were isolated, expanded, and
characterized based on our previous protocols (6). These
tests results were detected in the reference range required
for transfer to the patient (Figure 2).
R. Azeri, et al.
Acta Medica Iranica, Vol. 60, No. 4 (2022) 251
Figure 2. A) Flow cytometer analysis of WJ-MSC. A1; Positive expressions of CD90, CD105, CD44, CD73 markers and A2; negative
expressions of CD45/34/11b/HLA DR/19 marker cocktail. B) Gene expression profile of WJ-MSC. C) Mycoplasma PCR results on the agarose gel.
M: M: DNA ladder; 1: positive control; 2: negative control; 3: donor
The efficacy of allogeneic WJ-MSC treatment for our
patient was evaluated by five clinical evaluation test
parameters pre-/post-treatment measurements; Brooke
upper extremity scale, Vignos lower extremity scale,
muscle strength scale, functional independence measure,
and evaluation of Serum creatine kinase (CK) levels.
Based on comparison measurements taken at the pre-
and the post-term of treatment, the patient’s Brooke upper
extremity scale had decreased from 6 to 3. When the
general condition of the patient is evaluated, it was not
possible or even difficult to do daily hand skill activities
before the treatment. It was seen that there was little
difficulty or no difficulty in individual skills such as
writing, combing hair, eating after the treatment. The
Vignos lower extremity scale had dropped from 10 to 5,
so the patient showed improvement in independent
walking. It was recorded that the 6-meter area walked in
95 steps and approximately 2 minutes after the treatment,
while it was difficult to take 3-4 steps before the
treatment. The muscle strength scale elevated from 1 to
3, so there was a significant increase in muscle strength.
The functional independence measure was increased
from 3 to 27 out of 40. The patient has become capable of
activities that are restricted before the treatment, such as
dancing, rarely sitting at the table, eating, walking around
the house, writing, and writing. Although the CK level
was decreased from 232U/L to 140U/L, 9 months after
the treatment, it increased to 408U/L again. After the four
additional doses, the CK level was re-declined to 136 U/L
(Figure 3).
Wharton's jelly derived mesenchymal stem cell transplantation to a non-progressive congenital myopathy
252 Acta Medica Iranica, Vol. 60, No. 4 (2022)
Additionally, no serious side effects were observed in
the patient, who was observed by physicians on-site
consistently throughout the study.
Figure 3. Overall results of the evaluations tests. A) Total scale assessment of muscle function tests. B) The results of CK level after MSC
injections
Discussion
Our patient, diagnosed with Non-progressive
congenital myopathy, is a rare disease, got a homozygous
deletion in the SPEN1 gene at the 6th exon that causes
embryonic lethality due to defects in many vital tissue and
organ system formations, including the muscles (7).
Combining both the genetic background and the clinical
outcomes of the patient, SPEN1 mutations cause atrophy
of the adductor magus and biceps femoris muscles, which
have a major role in the grade of walking ability. As seen,
the increase in the Vignos-scale in post-treatment showed
the patient started walking without support. Likewise, it
has been reported that the CK levels in SPEN1 related
muscle disorders were measured 300-500IU/L (8).
Considering the effect of the increase in CK level causes
inflammation and necrosis of myofibers, the decrease in
CK level after allogenic WJ-MSC transplantation would
support the regression of the effects of the disease. As
seen in Figure 3, the CK level peaked again between the
6th dose and the additional 1st doses. Although each dose
was injected in monthly doses on average, the interval
between these 2 doses is 9 months. This gap reversed the
CK level with the increase of fibrosis. Decreasing with
the additional doses can be explained by immune evasive
and anti-inflammatory characteristics of MSCs via
suppressing T-cell functions by secreting PGE2,
secreting anti-inflammatory cytokines such as IL-10,
increasing the secretion of TNF-, IL1 and IL1 (6).
However, the increase in CK level shows us that repeated
MSC injections in genetic-based muscle disease are how
important and necessary.
One of the important factors determining the
effectiveness of the treatment depends on the
transplantation route of MSCs. Our cellular therapy for
this case was designed as three different transplantation
routes intra-arterial, intramuscular and intravenous. The
reason for choosing these routes were the anti-
inflammatory effects of both intramuscular and
intravenous injections; by the intramuscular injection, a
local regeneration as the lost tissue caused by the disease
triggers differentiation and triggers the formation of new
myofibrils can be provided (9), and a wider systemic
effect of intra-arterial (10).
The use of MSCs in the treatment of irreversible
muscle diseases has a significant place in regenerative
medicine. According to the National Institute of Health
Clinical Trials data, the importance of using MSC in the
translational treatment of muscular diseases is increasing.
There are 13 MSC treatment records for myopathy or
muscular disorders; four of them are WJ-MSC. This
increased acceleration of preferring WJ-MSC for muscle
diseases is the triggering proliferation by anti-apoptotic
effect, endogenous muscle cell precursors, and its
immunosuppression role for preventing fibrosis through
on myofibroblast via regulating the Extra Cellular Matrix
via its paracrine secretions (2,3). Besides the paracrine
secretions, MSCs also transfer their genomic material. As
we report, the 10-Duchenne Muscular Dystrophy patients
treated with WJ-MSC showed the restoring dystrophin
expression by cellular fusions explained by fusing with
the recipient cells to transfer its genomic material. So, the
deteriorated gene expression pattern related to the
myogenic differentiation may be impaired by SPEN1
might be regulated (6).
WJ-MSC transplantation may offer a better quality of
A) B
)
R. Azeri, et al.
Acta Medica Iranica, Vol. 60, No. 4 (2022) 253
life by alleviating the symptoms of this rare disease with
no treatment option that can be provided in conventional
methods. Although transplantation of WJ-MSC cannot
treat any genetic-based diseases, they may offer a more
comfortable life with slowing the progression rate,
regression of fibrosis, and immunoregulation (6). For all
that, new technologies, such as CRISPR/Cas9, might be
offering advanced these MSCs therapies with combining
the gene-editing approaches in the years to come.
Acknowledgments
The authors acknowledge Gökay Görmeli, Assoc.
Prof. Dr.; Sacit Karamürsel, Prof. Dr. and Gülşen Günel,
MSc. for their technical and clinical assistance.
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