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Ibarra Moreno CA, Silva HCA, Voermans NC, Jungbluth H, van den Bersselaar LR, Rendu J, Cieniewicz A, Hopkins PM, Riazi S. Myopathic manifestations across the adult lifespan of patients with malignant hyperthermia susceptibility: a narrative review. Br J Anaesth 2024:S0007-0912(24)00419-7. [PMID: 39107166 DOI: 10.1016/j.bja.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 08/09/2024] Open
Abstract
Malignant hyperthermia susceptibility (MHS) designates individuals at risk of developing a hypermetabolic reaction triggered by halogenated anaesthetics or the depolarising neuromuscular blocking agent suxamethonium. Over the past few decades, beyond the operating theatre, myopathic manifestations impacting daily life are increasingly recognised as a prevalent phenomenon in MHS patients. At the request of the European Malignant Hyperthermia Group, we reviewed the literature and gathered the opinion of experts to define MHS-related myopathy as a distinct phenotype expressed across the adult lifespan of MHS patients unrelated to anaesthetic exposure; this serves to raise awareness about non-anaesthetic manifestations, potential therapies, and management of MHS-related myopathy. We focused on the clinical presentation, biochemical and histopathological findings, and the impact on patient well-being. The spectrum of symptoms of MHS-related myopathy encompasses muscle cramps, stiffness, myalgias, rhabdomyolysis, and weakness, with a wide age range of onset mainly during adulthood. Histopathological analysis can reveal nonspecific abnormalities suggestive of RYR1 involvement, while metabolic profiling reflects altered energy metabolism in MHS muscle. Myopathic manifestations can significantly impact patient quality of life and lead to functional limitations and socio-economic burden. While currently available therapies can provide symptomatic relief, there is a need for further research into targeted treatments addressing the underlying pathophysiology. Counselling early after establishing the MHS diagnosis, followed by multidisciplinary management involving various medical specialties, is crucial to optimise patient care.
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Affiliation(s)
- Carlos A Ibarra Moreno
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology and Pain Management, University Health Network, Toronto, ON, Canada
| | - Helga C A Silva
- Malignant Hyperthermia Unit, Department of Anesthesiology, Pain and Intensive Care, Federal University of São Paulo, São Paulo, Brazil
| | - Nicol C Voermans
- Department of Neurology, Radboudumc Research Institute for Medical Innovation, Nijmegen, The Netherlands
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina London Children's Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK; Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine (FoLSM), King's College London, London, UK
| | - Luuk R van den Bersselaar
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands; Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - John Rendu
- Universite Grenoble Alpes, INSERM, Grenoble Institut Neurosciences, U1216, CHU Grenoble Alpes, Grenoble, France
| | - Agnieszka Cieniewicz
- Department of Anaesthesiology and Intensive Therapy, Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Philip M Hopkins
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK; Department of Anaesthesia, St James's University Hospital, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Sheila Riazi
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology and Pain Management, University Health Network, Toronto, ON, Canada.
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Cong Z, Wan T, Wang J, Feng L, Cao C, Li Z, Wang X, Han Y, Zhou Y, Gao Y, Zhang J, Qu Y, Guo X. Epidemiological and clinical features of malignant hyperthermia: A scoping review. Clin Genet 2024; 105:233-242. [PMID: 38148504 DOI: 10.1111/cge.14475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/22/2023] [Accepted: 12/07/2023] [Indexed: 12/28/2023]
Abstract
Malignant hyperthermia (MH) is a potentially fatal inherited pharmacogenetic disorder related to pathogenic variants in the RYR1, CACNA1S, or STAC3 genes. Early recognition of the occurrence of MH and prompt medical treatment are indispensable to ensure a positive outcome. The purpose of this study was to provide valuable information for the early identification of MH by summarizing epidemiological and clinical features of MH. This scoping review followed the methodological framework recommended by Arksey and O'Malley. PubMed, Embase, and Web of science databases were searched for studies that evaluated the epidemical and clinical characteristics of MH. A total of 37 studies were included in this review, of which 26 were related to epidemiology and 24 were associated with clinical characteristics. The morbidity of MH varied from 0.18 per 100 000 to 3.9 per 100 000. The mortality was within the range of 0%-18.2%. Identified risk factors included sex, age, disorders associated with MH, and others. The most frequent initial clinical signs included hyperthermia, sinus tachycardia, and hypercarbia. The occurrence of certain signs, such as hypercapnia, delayed first temperature measurement, and peak temperature were associated with poor outcomes. The epidemiological and clinical features of MH varied considerably and some risk factors and typical clinical signs were identified. The main limitation of this review is that the treatment and management strategies were not assessed sufficiently due to limited information.
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Affiliation(s)
- Zhukai Cong
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Tingting Wan
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Jiechu Wang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Luyang Feng
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Cathy Cao
- Department of Anesthesiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Xiaoxiao Wang
- Research Center for Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Yongzheng Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Yang Zhou
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Ya Gao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Jing Zhang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Yinyin Qu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
- Beijing Center of Quality Control and lmprovement on Clinical Anesthesia, Beijing, China
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Chang L, Gardner L, House C, Daly C, Allsopp A, Roiz de Sa D, Shaw MA, Hopkins PM. Comparison of Transcriptomic Changes in Survivors of Exertional Heat Illness with Malignant Hyperthermia Susceptible Patients. Int J Mol Sci 2023; 24:16124. [PMID: 38003313 PMCID: PMC10671540 DOI: 10.3390/ijms242216124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Exertional heat illness (EHI) is an occupational health hazard for athletes and military personnel-characterised by the inability to thermoregulate during exercise. The ability to thermoregulate can be studied using a standardised heat tolerance test (HTT) developed by The Institute of Naval Medicine. In this study, we investigated whole blood gene expression (at baseline, 2 h post-HTT and 24 h post-HTT) in male subjects with either a history of EHI or known susceptibility to malignant hyperthermia (MHS): a pharmacogenetic condition with similar clinical phenotype. Compared to healthy controls at baseline, 291 genes were differentially expressed in the EHI cohort, with functional enrichment in inflammatory response genes (up to a four-fold increase). In contrast, the MHS cohort featured 1019 differentially expressed genes with significant down-regulation of genes associated with oxidative phosphorylation (OXPHOS). A number of differentially expressed genes in the inflammation and OXPHOS pathways overlapped between the EHI and MHS subjects, indicating a common underlying pathophysiology. Transcriptome profiles between subjects who passed and failed the HTT (based on whether they achieved a plateau in core temperature or not, respectively) were not discernable at baseline, and HTT was shown to elevate inflammatory response gene expression across all clinical phenotypes.
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Affiliation(s)
- Leon Chang
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds LS9 7TF, UK; (L.C.); (M.-A.S.)
| | - Lois Gardner
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds LS9 7TF, UK; (L.C.); (M.-A.S.)
| | - Carol House
- Survival and Thermal Medicine Department, Institute of Naval Medicine, Alverstoke, Hampshire PO12 2DL, UK
| | - Catherine Daly
- Malignant Hyperthermia Unit, St James’s University Hospital, Leeds LS9 7TF, UK;
| | - Adrian Allsopp
- Survival and Thermal Medicine Department, Institute of Naval Medicine, Alverstoke, Hampshire PO12 2DL, UK
| | - Daniel Roiz de Sa
- Survival and Thermal Medicine Department, Institute of Naval Medicine, Alverstoke, Hampshire PO12 2DL, UK
| | - Marie-Anne Shaw
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds LS9 7TF, UK; (L.C.); (M.-A.S.)
| | - Philip M. Hopkins
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds LS9 7TF, UK; (L.C.); (M.-A.S.)
- Malignant Hyperthermia Unit, St James’s University Hospital, Leeds LS9 7TF, UK;
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An Overview of the Implications for Perianesthesia Nurses in terms of Intraoperative Changes in Temperature and Factors Associated with Unintentional Postoperative Hypothermia. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:6955870. [PMID: 35444780 PMCID: PMC9015883 DOI: 10.1155/2022/6955870] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/07/2022] [Accepted: 03/09/2022] [Indexed: 11/17/2022]
Abstract
Patients undergo surgery and anaesthesia on a daily basis across the United States and throughout the world. A major source of worry for these patients continues to be inadvertent hypothermia, once core temperature <36°C (96.8°F). Despite well-documented adverse physiological consequences, anaesthesia nurses continue to have a difficult task in keeping patient warmth pre-/peri-/post-surgical procedure. Thermostasis within postoperative patient necessitates the collaboration of many individuals. In order to provide safe and high-quality treatment, it is essential to use the most up-to-date data to guide therapeutic procedures targeted at achieving balance body temperature in surgical patients. Providing a review of the physiology of perioperative temperature variations and the comorbidities linked with accidental intraoperative hypothermia, this article will also provide preventive and treatment methods.
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Haematological, Biochemical and Hormonal Biomarkers of Heat Intolerance in Military Personnel. BIOLOGY 2021; 10:biology10101068. [PMID: 34681165 PMCID: PMC8533107 DOI: 10.3390/biology10101068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 01/31/2023]
Abstract
Simple Summary This study focuses on the biomarkers that are predictive of heat intolerance in military populations. Military personnel are at risk of exertional heat stroke when the body’s temperature increases during intense physical activity in hot weather. Exertional heat stroke (EHS) may accompany or precede heat intolerance, an unusual sensitivity to heat. However, it is unknown if blood biomarkers (haematological, biochemical and hormonal) are predictive of heat intolerance. We subjected a sample of Australian Defence Force personnel and civilian volunteers to a heat tolerance test (HTT), and blood samples were obtained pre-and post–HTT. The results showed that a history of EHS was associated with changes in creatinine and urea. The biochemical and hormonal biomarkers associated with heat intolerance were alanine amino transaminase, creatine kinase, cortisol and creatinine. Furthermore, creatinine and cortisol were identified as predictors and useful biomarkers of heat intolerance. This study also highlights the need for further exploration of genetic biomarkers to aid early identification and the return to duty process for military personnel who may be at risk of heat intolerance. Abstract Heat intolerance is the inability to withstand heat stress and this may occur due to exertional heat stroke (EHS). However, it is unknown if heat intolerance is associated with immune and hormonal disturbances. This study investigates haematological, biochemical and hormonal biomarkers related to heat intolerance and EHS in military and civilian volunteers. A quasi-experimental pre-and post-test design was used, with participants drawn from the Australian Defence Force (ADF) and the general populace. Blood samples were collected and analysed for biomarkers. Inferential statistics compared the biomarkers between the groups. Changes in alanine amino transaminase (p = 0.034), creatine kinase (0.044), cortisol (p = 0.041) and creatinine (p < 0.001) differed between the heat-intolerant and heat-tolerant groups. Participants with a history of EHS showed significant changes in creatinine (p = 0.022) and urea (p = 0.0031) compared to those without EHS history. Predictors of heat intolerance were increasing post-HTT creatinine and cortisol (OR = 1.177, p = 0.011 and OR = 1.015, p = 0.003 respectively). Conclusively, EHS history is associated with changes in creatinine and urea concentrations, while the predictors of heat intolerance are creatinine and cortisol. However, further exploration of other biomarkers, such as genetic polymorphism, is needed.
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Ayaş AO, Seçilmiş E, Ekicibil A. New application area for magnetocaloric materials: Hyperthermia method. J Mol Struct 2021. [DOI: 10.1016/j.molstruc.2021.130010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gardner L, Miller DM, Daly C, Gupta PK, House C, Roiz de Sa D, Shaw MA, Hopkins PM. Investigating the genetic susceptibility to exertional heat illness. J Med Genet 2020; 57:531-541. [DOI: 10.1136/jmedgenet-2019-106461] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/25/2019] [Accepted: 12/21/2019] [Indexed: 12/16/2022]
Abstract
BackgroundWe aimed to identify rare (minor allele frequency ≤1%), potentially pathogenic non-synonymous variants in a well-characterised cohort with a clinical history of exertional heat illness (EHI) or exertional rhabdomyolysis (ER). The genetic link between malignant hyperthermia (MH) and EHI was investigated due to their phenotypic overlap.MethodsThe coding regions of 38 genes relating to skeletal muscle calcium homeostasis or exercise intolerance were sequenced in 64 patients (mostly military personnel) with a history of EHI, or ER and who were phenotyped using skeletal muscle in vitro contracture tests. We assessed the pathogenicity of variants using prevalence data, in silico analysis, phenotype and segregation evidence and by review of the literature.ResultsWe found 51 non-polymorphic, potentially pathogenic variants in 20 genes in 38 patients. Our data indicate that RYR1 p.T3711M (previously shown to be likely pathogenic for MH susceptibility) and RYR1 p.I3253T are likely pathogenic for EHI. PYGM p.A193S was found in 3 patients with EHI, which is significantly greater than the control prevalence (p=0.000025). We report the second case of EHI in which a missense variant at CACNA1S p.R498 has been found. Combinations of rare variants in the same or different genes are implicated in EHI.ConclusionWe confirm a role of RYR1 in the heritability of EHI as well as ER but highlight the likely genetic heterogeneity of these complex conditions. We propose defects, or combinations of defects, in skeletal muscle calcium homeostasis, oxidative metabolism and membrane excitability are associated with EHI.
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