Corresponding Author: E. Karaoz

Department of Histology and Embryology, Faculty of Medicine, Istinye University, Istanbul, Turkey

Tel: +902129998099, Fax: +728188291209, E-mail address:

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 ( 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


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



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-


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



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.


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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