These result from defects in mitochondrial DNA. Clinical presentations vary greatly: muscle symptoms may include weakness, ophthalmoparesis, pain, or stiffness, or they may even be absent; age of onset ranges from infancy to adulthood; associated clinical presentations include ataxia, encephalopathy, seizures, stroke-like episodes, and recurrent vomiting. Three groups: CPEO; skeletal muscle–central nervous system syndromes; and pure myopathy syndromes simulating muscular dystrophy. The characteristic finding on muscle biopsy is “ragged red fibers,” which are muscle fibers with accumulations of abnormal mitochondria. Affected families often have a maternal pattern of inheritance because mitochondrial genes are inherited almost exclusively from the oocyte.