Lipid mediated ER-stress contributes to the pathogenesis of mitochondrial myopathies

Mitochondrial diseases are a heterogeneous group of genetic disorders caused by impaired oxidative phosphorylation (OxPhos). When skeletal muscle is predominantly affected, they are defined as primary mitochondrial myopathies. Although the genetic causes of mitochondrial myopathies and the resulting bioenergetic impairments are well established, the metabolic drivers behind progressive muscle dysfunction remain poorly defined. This gap in knowledge may contribute to the lack of effective treatments for these disorders. OxPhos defective muscle initiates a metabolic response coordinated by systemic signals which invokes the mobilization of fatty acids from white adipose tissue despite muscle inability to fully oxidize fatty acids due to OxPhos impairment. Here, we show that in human patients with mitochondrial disease and mice with OxPhos defective muscle, increased fatty acid mobilization from white adipose tissue leads to ectopic lipid accumulation and lipotoxicity in skeletal muscle. We find an increase in very long chain ceramides which are mechanistically linked to chronic ER stress, phosphorylation of eIF2, and activation of ATF4 signaling. We propose that Ph-eIF2-mediated attenuation of global protein synthesis and ATF4-initiated atrophy pathways contribute to muscle wasting and weakness. Importantly, inhibition of de novo synthesis of ceramides with myriocin reduces ER stress and improves muscle proteostasis, body weight, and motor functions in a conditional COX10 KO mouse model of mitochondrial myopathy. Together, these findings highlight altered lipid metabolism as a contributor of mitochondrial myopathy pathogenesis and identify lipid-mediated stress pathways that can be targeted therapeutically.