Kennedy disease

Kennedy's disease (KD) or X-linked spinal-bulbar muscular atrophy (SBMA) is a neuromuscular disease associated with mutations of the androgen receptor (AR). Because of its endocrine manifestations related to the impairment of the AR, it can be viewed as a variation of the disorders of the androgen insensitivity syndrome (AIS). It is named after WR Kennedy, a neurologist who was among the first to describe this disease.

Genetics
The gene for the androgen receptor is located on the X chromosome (Xq11-q12), making it a sex-linked disease, thus KD generally affects males. Females are rarely affected; female carriers tend to have a relatively mild expression of the disease if they show symptoms at all.

Pathology
Kennedy disease, reported in 1991, involves multiplied CAG repeats in the first exon (trinucleotide repeats). Inheritance is X-linked recessive with anticipation. Such a CAG repeat encodes a polyglutamine tract in a part of the androgen receptor outside of the binding sites. The more CAG repeats are present, the more severe the disease. The mechanism by which this type of mutaion causes neuromuscular disease is not completely understood, specifically as complete AIS does not affect neuromuscular activity. KD may share mechanistic features with other neurodegenerative disorders that are caused by polyglutamine expansion, such as Huntington's disease. There is currently no treatment or cure for Kennedy's Disease.

Signs and symptoms
Ages of onset and severity of manifestations in affected males vary from adolescence to old age, but most commonly develop in middle adult life. The latest onset was described in a male of 84 years of age. KD does not usually compromise longevity. The syndrome has neuromuscular and endocrine manifestations:

Neuromuscular
Early signs often include weakness of tongue and mouth muscles, fasciculations, and gradually increasing weakness of limb muscles with muscle wasting. In some cases, premature muscle fatigue begins in adolescence. Neuromuscular management is supportive, and the disease progresses very slowly and often does not lead to extreme disability.

Neurological: Muscular: Thoracic: Endrocrine Genito-Urinary: Miscellaneous Characteristics:
 * Bulbar Signs The Bulbar muscles are those supplied by the motor nerves coming off the brain stem which control breathing, swallowing, talking and other functions of the throat. Bulbar signs are problems with these functions.
 * Dysphagia Trouble swallowing. (One of the Bulbar signs.)
 * Intention Tremor Hand tremors when trying to do something.
 * Normal Babinski Normal plantar response, i.e., when the bottom of the foot is scraped, the toes bend down. An abnormal response would be an upward bendings of the toes indicating a problem in the brain itself.
 * Lower Motor Neuropathy The lower motor nerves are those that run from the spinal cord to the muscles that they stimulate to move. Loss of that nerve leads to weakness and wasting of the muscle.
 * Primary Sensory Neuropathy Numbness over certain areas. Loss of sensation.
 * Decreased or Absent Deep Tendon Reflexes. (When a doctor taps the knee with his hammer and nothing happens.)
 * Fasciculations Twitching of small muscles without purposeful movement that can be seen through the skin.
 * Cramps Large muscle spasms.
 * Postural Tremor Shaky muscles with certain positions.
 * Muscular Atrophy Wasting and shrinkage of muscles that occurs when the lower motor nerve does not stimulate the muscle adequately.
 * Hypertrophied Calves Calf muscles that become thicker because of cramps.
 * Gynecomastia (breast enlargement).
 * Androgen Deficiency Loss of masculinizing effect.
 * Estrogen Excess More of an apparent estrogen effect because of the lost of masulinizing effect.
 * Impotence Erectile dysfunction
 * Reduced Fertility Low sperm count
 * Testicular Atrophy Testicles become smaller and of less functional.
 * Late Apparent Onset Usually show symptoms late 30's and after
 * Slow Progression Near-normal lifespan
 * Asymmetry of Clinical Signs Muscles of one side may be more affected than the same muscles on the other side.

Homozygous females
Homozygous females, both of whose X chromosomes have a mutation leading to CAG expansion of the AR gene, have been reported to show only mild symptoms of muscle cramps and twitching. No endocrinopathy has been described.

History
This disorder was described by Kennedy in 1968. In 1991 it was recognized that the AR is involved in the disease process. The disease is probably more common than originally thought. A study in Scandinavia suggested a prevalence of 1.3/8,500 making KD the most common form of motor neuron disease in the specific area studied; nobody had been diagnosed before 1995. It has been suggested that some men with KD may be misdiagnosed to have amyotrophic lateral sclerosis (ALS, also Lou Gehrig's disease).