A mutation in the human ryanodine receptor gene associated with central core disease.

Central core disease (CCD) is a morphologically distinct, autosomal dominant myopathy with variable clinical features. A close association with malignant hyperthermia (MH) has been identified. Since MH and CCD genes have been linked to the skeletal muscle ryanodine receptor (RYR1) gene, cDNA sequence analysis was used to search for a causal RYR1 mutation in a CCD individual. The only amino acid substitution found was an Arg2434His mutation, resulting from the substitution of A for G7301. This mutation was linked to CCD with a lod score of 4.8 at a recombinant fraction of 0.0 in 16 informative meioses in a 130 member family, suggesting a causal relationship to CCD.

Malignant hyperthermia susceptibility. A light and electron microscopic study of endomyocardial biopsy specimens from nine patients.

Cardiomyopathy develops in some individuals who have a susceptibility to malignant hyperthermia. We studied right ventricular endomyocardial biopsy specimens from nine patients defined as having this disorder because of positive caffeine contracture tests on skeletal muscle biopsy specimens. Three patients had clinical evidence of cardiomyopathy and six did not. Light microscopy showed cytoplasmic contraction bands, perinuclear clearing, and a mild to moderate variation in myocyte and nuclear size. Ultrastructurally cytoplasmic contraction bands were associated with cardiac villi, myofiberlysis, and myofibrillolysis. These changes and occasional breaks in the sarcolemma were regarded as artefacts of the biopsy procedure. Megamitochondriosis with accompanying degenerative changes in the mitochondria were also seen and probably indicate increased cell metabolism; vacuolation of the cytoplasm was regarded as an "aging" phenomenon. Thus, the biopsy specimens were abnormal, but the changes were artefactual or nonspecific and were not unique to this group of patients. Biopsy did not provide a morphological explanation for abnormal cardiac function.

Bone mineral measurements of the central skeleton by in vivo neutron activation analysis for routine investigation os osteopenia.

In vivo neutron activation analysis has been used to measure bone mineral content in the central skeleton where osteoporotic fractures occur. To be of diagnostic value, the results must be normalized for body size. From data obtained from 74 healthy children and adults up to 55 years of age, we have found that the calcium in the central skeleton is approximately proportional to the cube of the subject's height. The correlation for the adults alone has an r value of 0.81. When data from both adults and children are used, r = 0.95. The validity of this cubic height relationship to the Ca concentration measurements has been further substantiated by studies on rats. The total femur calcium content of 110 rats from weanling to 25 weeks of age was proportional to the overall femur (length) 3.6 (or (length)2.6 per unit length) with r = 0.99. When the level of Ca content is related to data on normal subjects of the same body size (giving the Calcium Bone Index or CaBI) a good separation is obtained between normal volunteers and osteoporotic subjects. Volunteers who were 20 to 55 years of age had CABI 1.0 "/- .12 (SD) while osteoporotics had CaBI 0.69 +/- .10 (SD). When the calcium content as determined by in vivo activation analysis is expressed as a CaBI, it provides a powerful tool for the diagnosis of osteopenia. We suggest that all bone measurements, including peripheral ones, be normalized for body size in order to increase their diagnostic value.

Analysis of sarcoplasmic reticulum proteins in patients susceptible to malignant hyperthermia.

It has been suspected that the cause of malignant hyperthermia (MH) is an abnormality in the sarcoplasmic reticulum of skeletal muscle. We isolated the sarcoplasmic reticulum from malignant hyperthermia-susceptible (MHS) patients and controls and analysed the protein composition with sodium dodecyl sulfate polyacrylamide gel electrophoresis. There were no remarkable changes in the sarcoplasmic reticulum protein composition profile of the scanned gel of the patients. Quantitative measurement of the relative proportion of each band in the gel, however, revealed a slight decrease in calsequestrin and a slight increase in protein of molecular weight 23,000. (Ca2+ -Mg2+)ATPase had no altered subfragments in MHS patients. Crude mitochondrial proteins and myoplasmic proteins showed minor alterations in composition in some patients. The data supported the thesis that malignant hyperthermia is due to defects in several different cell membranes including the sarcoplasmic reticulum and the mitochondria.

Analysis of non-histone chromatin proteins in porcine malignant hyperthermia.

Non-histone chromatin proteins (NHCP) were isolated from skeletal muscle, left ventricle and liver of swine susceptible to malignant hyperthermia and from controls. These proteins were extracted with phenol buffers and fractionated by polyacrylamide gel electrophoresis. Isoelectrofocusing gel electrophoresis revealed quantitative differences in NHCP from skeletal muscle between disease and control groups. The high resolution of proteins by two-dimensional polyacrylamide gel electrophoresis showed a relative similarity between skeletal muscle, heart and liver although some differences could be discerned. Non-histone chromatin proteins of molecular weight 35,000-45,000, focusing between pH7 and 9, were increased in skeletal muscle nuclei derived from malignant hyperthermia-susceptible swine. These proteins appear to be important in the maturation of messenger RNA. No alterations were seen in either heart or liver. We conclude that an increase in NHCP which is associated with the processing of messenger RNA, may be important in the phenotypic expression in skeletal muscle of malignant hyperthermia in swine.

Malignant hyperthermia in the head and neck surgery patient: an update and review.

Malignant hyperthermia, a disorder often initiated by exposure to a variety of anesthetic agents, continues to be of major importance to the head and neck surgeon because: 1. approximately 40% of all reported reactions have occurred during anesthesia for head and neck surgery; 2. the possibility of mortality still exists despite the use of new pharmacologic agents, such as dantrolene; and, 3. subtle variations in the intraoperative and postoperative presentation of malignant hyperthermia are being increasingly recognized and treated. The authors briefly tabulate the 280 cases--which have occurred worldwide during otolaryngologic, dental, facial plastic, ophthalmologic and neurosurgical procedures--that are registered with the Department of Anaesthesia, University of Toronto, Canada. A case report depicting a less-than-typical reaction is presented. The authors emphasize that early recognition of the clinical features of an ongoing reaction, whether mild or severe, is by far the most important factor in reducing morbidity and mortality of patients who suffer hyperthermic crises while undergoing head and neck surgery.

Canine stress syndrome/malignant hyperthermia susceptibility: calcium-homeostasis defect in muscle and lymphocytes.

This study provides the first comprehensive characterisation of the calcium (Ca) homeostasis defects found in muscle and lymphocytes of a malignant hyperthermia (MH)-susceptible dog. Novel findings regarding this dog are reported, compared to controls. First, a canine stress syndrome occurs, analogous to the porcine stress syndrome; susceptibility can be identified by exercise challenge testing. Secondly, caffeine causes Ca release from muscle sarcoplasmic reticulum in a greater amount and at a greater rate. Thirdly, there is a compensatory increase in Ca sequestration by sarcoplasmic reticulum. Fourthly, lymphocytes have lower cytosolic-free Ca and a greater ability to prevent Ca increase. Halothane increases Ca by a greater amount and rate. Fifthly, muscle is more resistant to the contracture-producing effects of caffeine, as occurs in the non-rigid variant of MH susceptibility in man. This resistance, despite increased caffeine-induced release through the Ca channel, may be attributable to increased Ca sequestration by sarcoplasmic reticulum. Finally, erythrocyte osmotic fragility and creatine kinase tests fail to distinguish between the MH-susceptible dog and controls.

Malignant hyperthermia susceptibility: biochemical basis for pathogenesis and diagnosis.

Malignant hyperthermia (MH) is a hypermetabolic and hypercontractile syndrome triggered by anesthesia or various stressors that cause a sustained increase in sarcoplasmic ionized Ca. Susceptibility is apparently inherited in an autosomal dominant pattern. The primary molecular defect results in hypersensitive ligand-gating of the Ca-release channel of sarcoplasmic reticulum (SR) in skeletal muscle: channel opening is stimulated by abnormally low concentrations of agonist. We attribute MH to a mutation in the gene for the fast twitch muscle isoform of the Ca-channel, resulting in the expression of a cardiac-like isoform in fast muscle. Syndromes with some resemblance to MH can occur due to other genetic or acquired imbalances in Ca-flux across SR that favor net release of Ca. Either defective uptake or release can be detected as increased sensitivity of muscle to the contracture-producing effects of caffeine and halothane. Thus, caffeine and/or halothane contracture tests for MH-susceptibility may give false positives when there is decreased Ca-uptake, such as in muscular dystrophies. Ca-channel hypersensitivity and decreased Ca-uptake activity can be detected by assays using isolated SR. Functional assays using lymphocytes are being assessed as potential replacements for muscle contracture tests. Polymorphism analysis of proteins or nucleic acids for the MH or closely-linked genes has been used to trace the inheritance of MH-susceptibility.

Failure of the platelet-halothane nucleotide depletion test as a diagnostic or screening test for malignant hyperthermia.

A platelet-halothane nucleotide or bioassay test has been suggested as an accurate means for diagnosis of malignant hyperthermia (MH). For the last three years we performed this test in all patients at risk for MH and in all normal control patients undergoing skeletal muscle biopsy in our diagnostic unit. The reliability of the platelet-halothane nucleotide test has been assessed on the basis of the presence or absence of a previous MH reaction and degree of relationship of relatives to those who have had reactions, and on the basis of caffeine-halothane contracture test values (positive or negative for MH). We have found no significant difference in platelet-halothane nucleotide test values in malignant hyperthermia susceptible (MHS) patients or relatives of MHS patients and normal controls, and no relationship between the nucleotide test and caffeine-halothane contracture test results. We conclude that the platelet-halothane nucleotide test is not of assistance in the diagnosis of or in the screening for MH.

Malignant hyperthermia.

Malignant hyperthermia is a hereditary trait characterized by hypercatabolic reactions induced by anesthetic drugs, or physical or emotional stress. Patients must be treated quickly and efficiently in order to prevent irreversible organ damage and death.

In vivo neutron activation analysis for bone calcium (INVAA) in malignant hyperthermia susceptible patients.

Some non-rigid Malignant Hyperthermia Susceptible (MHS) patients have a greater than normal incidence of fractures. Radiologically their long bones are slightly thinner than normal. Excessive numbers of caries because of thin dental enamel may also be present. The Malignant Hyperthermic (MH) defects thus appears to involve cells of bone appendages as well as of muscle. We have measured the concentration of calcium in bone by neutron activation analysis and have found it to be reduced in both non-rigid and rigid malignant hyperthermia susceptible patients. The reductions were particularly marked for the non-rigid patients. Bone calcium concentrations were lower in males than in females and in those under 16 and over 60 years of age. This is additional evidence is favour of the hypothesis that malignant hyperthermia is a widespread defect affecting tissues and organs throughout the body.

Calcium uptake into muscle of pigs susceptible to malignant hyperthermia: in vitro and in vivo studies with and without halothane.

MHS and normal pigs were anaesthetized with nitrous oxide and diazepam. Halothane 1% was then administered for 1 hr. Immediately before and immediately after the halothane inhalation, 10 g of vastus lateralis muscle was excised. SR was isolated from this muscle. Calcium accumulation by the MHS sarcoplasmic reticulum in the absence of halothane was greater than normal. Halothane in vitro produced a similar increase in calcium uptake into both the MHS and the normal SR. Halothane in vivo significantly reduced calcium accumulation by hyperthermic SR but had no significant effect on calcium uptake into the normal SR. Thus the action of halothane on the MHS sarcoplasmic reticulum is indirect, occurring only in the intact cell. It is possibly a result of the deleterious effect which lack of ATP, a low pH or a high temperature is likely to have on the calcium accumulating mechanism of the SR membrane. Our results suggest that the primary defects of porcine and human malignant hyperthermia are not entirely synonymous.

Incidence of malignant hyperthermia reactions in 2,214 patients undergoing muscle biopsy.

To determine the incidence of malignant hyperthermia (MH) reactions after trigger-free anaesthesia in a large population of MH-susceptible (MHS) patients, the charts of 2,214 patients who underwent elective muscle biopsy for malignant hyperthermia were reviewed. Either general or regional anaesthesia with non-triggering drugs was used. For general anaesthesia, the trachea was intubated in the absence of muscle relaxants. The halothane/caffeine contracture test was performed on the biopsied muscle. Suspected MH reactions were identified according to their site of occurrence (in the operating room, recovery room or ward). Ninety-seven percent of patients received a general anaesthetic; 3% received a regional anaesthetic or field block. Of the 2214 patients whose muscles were biopsied, 1082 patients were biopsy-positive for MH. Five patients in whom MH reactions were diagnosed in the recovery room were all subsequently proved to be biopsy-positive for MH. Four of the five received intravenous dantrolene as part of their therapy; the fifth received only symptomatic therapy as parenteral dantrolene was not commercially available. All patients recovered completely from their reactions. We conclude that the incidence of MH reactions in biopsy-positive patients who receive a trigger-free anaesthetic for minor surgery is small (0.46%, (0.15-1.07%, 95% CI)). These reactions occur in the immediate postoperative period.

Selective increase in cytoplasmic calcium by anesthetic in lymphocytes from malignant hyperthermia-susceptible pigs.

Anesthetic-induced malignant hyperthermia in pigs and humans is characterized by muscle rigidity and rapid, often fatal, increases in body temperature. A defect in Ca2+ homeostasis has been suspected as underlying the disease, based on the preventive effect of dantrolene sodium, an agent thought to reduce Ca2+ levels in the cytoplasm. We describe here direct measurements of cytoplasmic ionized Ca2+ levels in lymphocytes from seven normal and 12 malignant hyperthermia-susceptible pigs, using the fluorescent indicator quin2. No differences in the concentration of cytoplasmic ionized Ca2+ were found in cells from malignant hyperthermia-susceptible pigs (160 +/- 10 nM) relative to the controls (150 +/- 10 nM). However, addition of halothane in vitro caused a significant increase (to 270 +/- 30 nM) in lymphocytes from malignant hyperthermia-susceptible pigs, but not from normal pigs (180 +/- 10 nM). The halothane-mediated increase in cytoplasmic ionized Ca2+ required extracellular Ca2+. It is suggested that general anesthetics such as halothane increase the permeability of the cell surface to Ca2+, and that this increase may, on its own or indirectly, increase the cytoplasmic level of ionized Ca2+ during a malignant hyperthermia crisis. The detection of a halothane-dependent increase in cytoplasmic ionized Ca2+ selectively in malignant hyperthermia-susceptible pigs could be the basis for a noninvasive test for malignant hyperthermia.