I’ve Got That One. It’s called SMA Type II. And now it finally matters!

Note: To those of you who have heard this story before, please keep reading to the end. There is a new ending and I don’t want to give it away. Please keep reading.

Approximately 40 years ago I applied for a job as a computer programmer at the Indiana University Department of Medical Genetics which in those days was housed in the research wing of Riley Hospital for Children. My mentor and computer professor Dr. John Gersting was a consultant to the project and helped me secure the job despite his insistence that he would not help and I had to earn it on my own. He attended the job interview which was conducted by the department chairman Dr. Donald Merritt MD, PhD.

To put it mildly, Dr. Merritt was an asshole. Somewhere during the course of the interview Merritt and my mentor Gersting exchange some snarky joke with one another and Merritt flipped the bird at Gersting. Dr. Gersting looked at him as if to say “Why the fuck would you behave in such a childish manner in front of one of my pet students? Are you really so inarticulate that you have to stoop to flipping me off in front of him?” But in fact he said nothing. He didn’t need to.

At one point during the job interview Dr. Merritt asked me “What’s your diagnosis?”

I didn’t understand. I thought he wanted me to diagnose something. He rephrased the question “With what were you diagnosed? What you got? Why are you in the wheelchair?”

“Oh now I understand” I replied. “It’s some kind of muscular dystrophy or genetic neuromuscular disease. As you well know there are a dozen or so different varieties. I’ve never bothered to figure out which one I have. It’s not Duchenne muscular dystrophy obviously. There is genetic history in my family. The people here at Riley described it as ‘amytonia congenita’ but that’s not really a diagnosis it’s more description of my symptoms.” That particular Latin phrase means congenital (since birth) low muscle tone. I always said it was like they took me into the doctors and said “hey this kid has had weak muscles since birth” and the doctor said “We’ve got a name for that… amytonia congenita” and we said “What’s that mean?” and they said “it’s Latin for this kid has had weak muscles since birth”. It sounds so much more formal in Latin it doesn’t it?

“But don’t you want to know?” He inquired.

“Well Doc… When you can tell me which of those dozen or so types of muscular dystrophy you can do anything to help… Then I’ll worry about whether or not I’ve got that one.”

He raised his eyebrows as if to say “okay you got me there.” He went on to explain there were other reasons one might want to know one’s diagnosis. If I have siblings they might want to know if they were at risk to bear children with my disability etc. I told him we would deal with that at the proper time.

He went on to explain very matter of fact that his true purpose was to see if I was comfortable discussing my own disability. He had experienced people who were shy about discussing such issues and considering the way I threw it back in his face I had alleviated any concerns about my shyness or timidity on the topic. The interview went on and I got the job. I worked there for two years until my disability brought on congestive heart failure and other issues that made it no longer possible for me to work a full-time job.

Approximately 25 years later while doing some Google searches about medical conditions for a friend, I decided to look up “amytonia congenita”. Among the websites found were my own blog where I explained my connection to the phrase. Another was a quote from a book jacket on amazon.com for an autobiography titled “The Me in the Mirror” by Connie Panzarino. It said that the author had “Spinal Muscular Atrophy Type II, formerly known as amytonia congenita”. That peaked my interest. Whatever the hell “Spinal Muscular Atrophy Type II” was… It sounded much more like a real diagnosis than a symptom description like amytonia congenita.

I continued searching about Spinal Muscular Atrophy or SMA as it was abbreviated and as I read the descriptions of patients many in their own words, it sounded as though they could’ve been my twins. The course of their disease sounded identical to my own experiences.

One of the things that had made me reluctant to determine what type of muscular dystrophy I had was that the diagnosis process generally involves things like electrical stimulations of muscles and muscle biopsies neither of which sounded very unpleasant simply to answer a question that yielded no useful answers. However SMA was known to be caused by a missing chunk of DNA in my number 5 chromosome. Specifically it is missing from a gene known as the SMN1 gene. Genes are strands of DNA which create specific proteins. They are divided into coded sections called axions and non-coded sections called interons. The seventh axion of the SMN1 is missing in patients with SMA. It’s like you cut the tape and spliced it back together again. All they had to do was take a DNA sample in the form of a blood sample. They would send it off to a lab and sequence that gene and see if than chunk was missing.

Everyone has two copies of each chromosome with one coming from their mother and the other from their father. If you have a missing chunk from one parent but not the other you are a carrier but do not exhibit the disease. If both parents give you DNA with a missing chunk (a 1 out of 4 chance) then you hit the DNA lottery and end up with SMA like me. Whoops… Spoilers… The DNA test came back saying indeed I did have a missing 7 axion from both copies of my 5 chromosome.

Where did I go to get the test done? I went back to the Indiana University Department of Medical Genetics where I had worked as a computer programmer 25 years earlier. Dr. Merritt had died of skin cancer shortly after that job interview. After I left the department it moved to new buildings at the IU Medical Center. But some of the people who were there when I was were still working there and they had a vague recollections of the guy in the wheelchair who worked on the “Mega-dats” computer database all those years ago.

One thing that did not change over those 25 years. There still wasn’t anything they could do for it. But it was fascinating to know they really did know what was wrong with me. In the years since my diagnosis I have followed the course of the research. For example they have developed a strain of lab rats that have the disease which is useful. They’ve come up with a variety of strategies for possibly treating the disease.

I mentioned that the problem is a missing chunk from SMN1 gene which encodes something called the SMN protein the lack of which causes my disease. I can go into more detail on how it works but that’s unimportant for the current discussion. Everyone, whether they have SMA or not also has in their 5 chromosome something called the SMN2 gene sometimes called a backup gene that should kick in if there’s something wrong with SMN1. The problem is everyone’s SMN2 gene has a glitch of its own. Just one base pair in the strand of DNA (I forget whether it’s a AG or a CT that is swapped) is wrong. Think of it as a one bit data error in a strand of data thousands of bits long. That one bit error means that the SMN2 gene only creates the proper protein about 20% of the time. The other 80% create some worthless molecule that does nothing useful.

One of the strategies has been to get SMN2 to turn itself on five times more than usual. That way when it only works 20% of the time you get 5×20% equals 100% of what’s needed. The other strategy is to introduce a drug that increases that percentage so that it works more often. It doesn’t correct the bad bit of data but it causes the protein to get properly manufactured despite the flipped bit. That strategy is one employeed by a drug known as “Spinraza”. But more on that later…

I said that I have SMA Type II. In my particular case I never walked as an infant and the disease has progressed relatively slowly throughout my 61+ years on the planet. A more severe and more common version is SMA Type I in which infants are born severely weakened and rarely survive more than a few months. It is the number one genetic killer of any disease known. There is also an SMA Type III which has a later onset than mine and therefore consequently less severe. The goal of course of most treatment strategies is to try to get those Type I babies to survive more than a few months. A successful treatment is easy to measure because they wouldn’t die. Measuring success in Type II or III is more difficult because the disease progresses more slowly.

Okay… I can’t stand it anymore.

I have buried the lead of the story as deep as I can.

Today, December 23, 2016, the FDA has approved the use of the drug Spinraza for the treatment of Spinal Muscular Atrophy Type I, II and III. In clinical trials with a double-blind study of 121 patients with SMA Type I, results showed that 40% of the patients receiving the drug showed measurable efficacy measured by a variety of standards including extended survival while those receiving a placebo had no benefit. The drug is so effective that all participants are now receiving the actual drug. It is been fast tracked and approved for all types of SMA including mine.

The treatment involves injection into the spinal fluid. I’m not sure how often such injections are required. If you can do it on their program they will cover the cost of the drug. This is also hot off the press there isn’t much information available right now.

Obviously for someone like me who has endured the effects of the disease for 61 years even if this was an all-out cure (and no one is calling it that… They are calling it a treatment) nothing is going to reverse the orthopedic effects of contracted joints, severe scoliosis, muscle deterioration, nerve damage etc. that can come with the course the disease throughout my life. I’ve always known that as I followed the research. To the parents of those Type I babies however it’s the miracle they’ve all been praying for.

But finally Dr. Merritt, wherever you are, they can do something about one of those types of muscular dystrophy. And guess what… It’s the one I got!

And I discovered the news by a Facebook post from CureSMA.org while sitting alone in room 207 of St. Vincent Seton Specialty Hospital two days before Christmas while waiting on bureaucracy to get me a ventilator so I can go home.

Here are two articles with details on the above story.

FDA Approves Spinraza for SMA

FDA approves first drug for spinal muscular atrophy

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