Spinal and bulbar muscular atrophy (SBMA), popularly known as Kennedy's disease, is a rare, adult-onset, X-linked recessive lower motor neuron disease caused by trinucleotide CAG repeat expansions in exon 1 of the androgen receptor (AR) gene, which results in both loss of AR function and toxic gain of function. In males, the disease slowly progresses over decades with bulbar and lower motor neuron loss, muscle denervation, and direct skeletal muscle involvement. The disease causes progressive muscle loss with weakness, fasciculations, and cramps. Weakness of the bulbar muscles follows causing difficulties in speech (dysarthria) and swallowing (dysphagia). Female carriers do not show symptoms. Although there is no cure, supportive intervention can improve mobility and reduce complications. The prevalence of SBMA has been estimated at 2.6:100,000 males. There is no known cure for SBMA. Supportive care is focused on preventing disease complications and maintaining independence.
Signs and symptoms Neuromuscular symptoms include muscle weakness and wasting of the limb, bulbar and respiratory muscles, tremor, fasciculations, muscle cramps, speech and swallowing difficulties, decreased or absent deep tendon reflexes, and sensory neuropathy. Other manifestations of SBMA include androgen insensitivity (gynecomastia, erectile dysfunction, reduced fertility, testicular atrophy), and metabolic impacts (glucose resistance, hyperlipidemia, fatty liver disease).
Neuromuscular effects SBMA patients develop limb weakness which often begins in the pelvic or shoulder regions between 30 and 50 years of age. Muscle strength declines slowly, at a rate of approximately 2% per year based on quantitative muscle assessment. Muscle weakness often begins in proximal muscles, with most patients first noticing weakness in their lower limbs. Tremor, fasciculations, and cramps are common early symptoms of SBMA. Tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving oscillations or twitching movements. In SBMA patients, tremor is most common in the hands, but also occur in the head, voice and lower limbs, and may be observed ten years prior to muscle weakness. Fasciculation, or fleeting muscle twitches visible under the skin, is a spontaneous, involuntary muscle contraction and relaxation, and is especially noticeable in the face and tongue of SBMA patients. Lingual atrophy occurs later in the course of the disease, but the tongue may develop an unusual shape due to coexisting denervation and reinnervation. A cramp is a sudden, involuntary, painful skeletal muscle contraction of skeletal muscle, and common in motor neuron disorders. Bulbar symptoms (weakness of the facial and tongue muscles) typically follow limb manifestations and may start with difficulty with speech articulation (dysarthria) before swallowing difficulty (dysphagia). Dysarthria is common, with hypernasality due to incomplete lifting of soft palate, but typically remains relatively mild and seldom leads to the loss of oral communication. Signs of dysphagia include difficulty controlling solids, liquids or saliva in the mouth, coughing and choking. As the disease progresses, there is increased risk of aspiration pneumonia, which is the leading cause of death in SBMA patients. Up to half of all patients experience laryngospasm, an uncontrolled contraction (spasm) of the vocal folds, with a sense of choking, and feel that the air cannot enter or exit the airways for long seconds. Laryngospasms are often followed by a high-pitched breathing sound (stridor) due to rapid and vigorous contraction of the laryngeal sphincters. This is a frightening and hugely distressing experience, but rarely escalates to prolonged or serious episodes. In SBMA, deep tendon reflexes are diminished or absent. Sensory involvement results in degeneration of dorsal root ganglion cells with reduced vibratory sensation (distally in the legs), neuropathic pain, and numbness. There are sporadic reports of certain psychological traits (lack of self-confidence, emotional flattening, and poor concentration), but detailed neuropsychological examination of 64 SBMA patients did not detect any abnormalities.
Androgen insensitivity Loss of AR function in SBMA patients results in partial androgen insensitivity, including gynecomastia, erectile dysfunction, decreased libido, infertility and testicular atrophy. Patients with complete androgen insensitivity syndrome do not show symptoms of SBMA, indicating neuromuscular symptoms are not caused by a loss of AR function. Gynecomastia, excessive enlargement of male breasts, is observed in about three quarters of SBMA patients. It typically becomes apparent after puberty, and is often the first evidence of this disease. Erectile dysfunction, decreased libido, infertility and testicular atrophy are common. One of the most disease-specific endocrine indices of SBMA is the androgen sensitivity index (luteinizing hormone / testosterone) which is elevated in 64% of cases, indicating both endocrine and exocrine testicular dysfunction.
Metabolic disturbances Metabolic disturbances have also been reported in SBMA patients, with increased risk of insulin resistance, fatty liver disease, hyperlipidemia, and electrocardiogram (ECG) abnormalities. Impaired glucose homeostasis is a common feature of SBMA, and recent study found a significant correlation between insulin resistance and motor dysfunction in SBMA. In a group of 22 patients with SBMA, evidence of fatty liver disease was detected in all individuals by magnetic resonance spectroscopy. In a second group, liver dome magnetic resonance spectroscopy measurements were increased in participants with SBMA relative to age- and sex-matched controls. SBMA patients may have higher frequency of Brugada syndrome and other electrocardiogram (ECG) abnormalities, which if not detected, can lead to sudden death. There are no reports of cardiomyopathy. However, there are indications that SBMA patients may be more likely to have high blood pressure and elevated total cholesterol and triglycerides.
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