MK4 Repositioning for IAHSP: Overcoming In Vivo Data Gaps through In Silico Refinement and In Vitro Validation.

Infantile-onset Ascending Hereditary Spastic Paralysis (IAHSP) is an ultrarare, autosomal recessive form of Hereditary Spastic Paraplegia (HSP), caused by mutations in the ALS2 gene, which encodes the protein ALSIN. In a previous study, we proposed a personalized therapeutic strategy for an Italian IAHSP patient (AO), aiming to correct the aberrant function of the R1611W mutant ALSIN using Menatetrenone (MK4). While our results supported compassionate-use approval for a patient-specific therapeutic regimen, further investigation was needed to highlight the treatment's benefits in the absence of tractable biophysical assays and in vivo models. In this respect, we first characterized MK4's interaction with the mutation site through Molecular Dynamics simulations. Next, we established and characterized a skin fibroblast cell line derived from patient AO. We analyzed the expression and stability of the mutant ALSIN protein in AO's fibroblasts and observed elevated oxidative stress levels. Using advanced microscopy and automated image analysis, we identified a characteristic mitochondrial phenotype associated with AO's IAHSP. One specific morphological parameter of mitochondria (Mean Branch Diameter) accurately reflected the IAHSP phenotype and was selected as a cell marker. Treatment of IAHSP fibroblasts with MK4 highlighted the rescue of Mean Branch Diameter and ALSIN levels, supporting cellular efficacy. Overall, this work presents an approach that integrates computational and cell-based methodologies to overcome the data scarcity challenges of drug discovery in rare diseases. Our study provides a framework for preclinical, alternative drug discovery programs in monogenic rare disorders such as IAHSP.