1
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Todd JJ, Lawal TA, Chrismer IC, Kokkinis A, Grunseich C, Jain MS, Waite MR, Biancavilla V, Pocock S, Brooks K, Mendoza CJ, Norato G, Cheung K, Riekhof W, Varma P, Colina-Prisco C, Emile-Backer M, Meilleur KG, Marks AR, Webb Y, Marcantonio EE, Foley AR, Bönnemann CG, Mohassel P. Rycal S48168 (ARM210) for RYR1-related myopathies: a phase one, open-label, dose-escalation trial. EClinicalMedicine 2024; 68:102433. [PMID: 38318125 PMCID: PMC10839573 DOI: 10.1016/j.eclinm.2024.102433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 02/07/2024] Open
Abstract
Background RYR1-related myopathies (RYR1-RM) are caused by pathogenic variants in the RYR1 gene which encodes the type 1 ryanodine receptor (RyR1). RyR1 is the sarcoplasmic reticulum (SR) calcium release channel that mediates excitation-contraction coupling in skeletal muscle. RyR1 sub-conductance, SR calcium leak, reduced RyR1 expression, and oxidative stress often contribute to RYR1-RM pathogenesis. Loss of RyR1-calstabin1 association, SR calcium leak, and increased RyR1 open probability were observed in 17 RYR1-RM patient skeletal muscle biopsies and improved following ex vivo treatment with Rycal compounds. Thus, we initiated a first-in-patient trial of Rycal S48168 (ARM210) in ambulatory adults with genetically confirmed RYR1-RM. Methods Participants received 120 mg (n = 3) or 200 mg (n = 4) S48168 (ARM210) daily for 29 days. The primary endpoint was safety and tolerability. Exploratory endpoints included S48168 (ARM210) pharmacokinetics (PK), target engagement, motor function measure (MFM)-32, hand grip and pinch strength, timed functional tests, PROMIS fatigue scale, semi-quantitative physical exam strength measurements, and oxidative stress biomarkers. The trial was registered with clinicaltrials.gov (NCT04141670) and was conducted at the National Institutes of Health Clinical Center between October 28, 2019 and December 12, 2021. Findings S48168 (ARM210) was well-tolerated, did not cause any serious adverse events, and exhibited a dose-dependent PK profile. Three of four participants who received the 200 mg/day dose reported improvements in PROMIS-fatigue at 28 days post-dosing, and also demonstrated improved proximal muscle strength on physical examination. Interpretation S48168 (ARM210) demonstrated favorable safety, tolerability, and PK, in RYR1-RM affected individuals. Most participants who received 200 mg/day S48168 (ARM210) reported decreased fatigue, a key symptom of RYR1-RM. These results set the foundation for a randomized, double-blind, placebo-controlled proof of concept trial to determine efficacy of S48168 (ARM210) in RYR1-RM. Funding NINDS and NINR Intramural Research Programs, NIH Clinical Center Bench to Bedside Award (2017-551673), ARMGO Pharma Inc., and its development partner Les Laboratoires Servier.
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Affiliation(s)
- Joshua J. Todd
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814, USA
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20814, USA
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Tokunbor A. Lawal
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20814, USA
| | - Irene C. Chrismer
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20814, USA
| | - Angela Kokkinis
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814, USA
| | - Christopher Grunseich
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814, USA
| | - Minal S. Jain
- Mark O. Hatfield Clinical Research Center, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD 20814, USA
| | - Melissa R. Waite
- Mark O. Hatfield Clinical Research Center, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD 20814, USA
| | - Victoria Biancavilla
- Mark O. Hatfield Clinical Research Center, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD 20814, USA
| | - Shavonne Pocock
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20814, USA
| | - Kia Brooks
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814, USA
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Christopher J. Mendoza
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814, USA
| | - Gina Norato
- Clinical Trials Unit, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Ken Cheung
- Mailman School of Public Health, Columbia University, NY 10032, USA
| | - Willa Riekhof
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20814, USA
| | - Pooja Varma
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20814, USA
| | - Claudia Colina-Prisco
- Section of Sensory Science and Metabolism, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD 20814, USA
| | - Magalie Emile-Backer
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20814, USA
| | - Katherine G. Meilleur
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20814, USA
| | - Andrew R. Marks
- Department of Physiology and Cellular Biophysics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY 10032, USA
| | - Yael Webb
- ARMGO Pharma, Inc, Ardsley, NY 10591, USA
| | | | - A. Reghan Foley
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814, USA
| | - Carsten G. Bönnemann
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814, USA
| | - Payam Mohassel
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814, USA
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Jang EJ, Kim JS, Choi SA, Yee J, Song TJ, Park J, Gwak HS. Construction of a risk scoring system using clinical factors and RYR2 polymorphisms for bleeding complications in patients on direct oral anticoagulants. Front Pharmacol 2023; 14:1290785. [PMID: 38034995 PMCID: PMC10684747 DOI: 10.3389/fphar.2023.1290785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction: Bleeding is one of the most undesirable complications of direct oral anticoagulants (DOACs). While the ryanodine receptor (RYR2) has been related to cardiac diseases, research on bleeding complications is lacking. This study aimed to elucidate the association between RYR2 and bleeding risk to develop the risk scoring system in patients treated with DOACs. Methods: This study was a retrospective analysis of prospectively collected samples. We selected ten SNPs within the RYR2 gene, and two models were constructed (Model I: demographic factors only, Model II: demographic and genetic factors) in multivariable analysis. Independent risk factors for bleeding were used to develop a risk scoring system. Results: A total of 447 patients were included, and 49 experienced either major bleeding or clinically relevant non-major bleeding. In Model I, patients using rivaroxaban and experiencing anemia exhibited an increased bleeding risk after adjusting for covariates. Upon incorporating genetic factors into Model I, a significant association with bleeding was also observed in cases of overdosing on DOACs and in patients with a creatinine clearance (CrCl) < 30 mL/min, in addition to rivaroxaban and anemia (Model II). Among genetic factors, RYR2 rs12594 GG, rs17682073 AA, rs3766871 GG, and rs6678625 T alleles were associated with bleeding complications. The area under the receiver operating characteristic curve (AUROC) of Model I was 0.670, whereas that of Model II increased to 0.803, demonstrating better performance with the inclusion of genetic factors. Using the significant variables in Model II, a risk scoring system was constructed. The predicted bleeding risks for scores of 0, 1-2, 3-4, 5-6, 7-8, and 9-10 points were 0%, 1.2%, 4.6%, 15.7%, 41.7%, and 73.3%, respectively. Conclusion: This study revealed an association between RYR2 and bleeding complications among patients taking DOACs and established a risk scoring system to support individualized DOAC treatment for these patients.
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Affiliation(s)
- Eun Jeong Jang
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Jung Sun Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Seo A. Choi
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Tae-Jin Song
- Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Junbeom Park
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
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3
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Baker EK, Al Gharaibeh FN, Bove K, Calvo-Garcia MA, Shillington A, VandenHeuvel K, Cortezzo DE. A novel RYR1 variant in an infant with a unique fetal presentation of central core disease. Am J Med Genet A 2023; 191:1646-1651. [PMID: 36965156 DOI: 10.1002/ajmg.a.63188] [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: 01/03/2023] [Revised: 02/20/2023] [Accepted: 03/13/2023] [Indexed: 03/27/2023]
Abstract
Ryanodine receptor type 1-related disorder (RYR1-RD) is the most common subgroup of congenital myopathies with a wide phenotypic spectrum ranging from mild hypotonia to lethal fetal akinesia. Genetic testing for myopathies is imperative as the diagnosis informs counseling regarding prognosis and recurrence risk, treatment options, monitoring, and clinical management. However, diagnostic challenges exist as current options are limited to clinical suspicion prompting testing including: single gene sequencing or familial variant testing, multi-gene panels, exome, genome sequencing, and invasive testing including muscle biopsy. The timing of diagnosis is of great importance due to the association of RYR1-RD with malignant hyperthermia (MH). MH is a hypermetabolic crisis that occurs secondary to excessive calcium release in muscles, leading to systemic effects that can progress to shock and death if unrecognized. Given the association of MH with pathogenic variants in RYR1, a diagnosis of RYR1-RD necessitates an awareness of medical team to avoid potentially triggering agents. We describe a case of a unique fetal presentation with bilateral diaphragmatic eventrations who had respiratory failure, dysmorphic facial features, and profound global hypotonia in the neonatal period. The diagnosis was made at several months of age, had direct implications on her clinical care related to anticipated need to long-term ventilator support, and ultimately death secondary an arrhythmia as a result of suspected MH. Our report reinforces the importance of having high suspicion for a genetic syndrome and pursuing early, rapid exome or genome sequencing as first line testing in critically ill neonatal intensive care unit patients and further evaluating the pathogenicity of a variant of uncertain significance in the setting of a myopathic phenotype.
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Affiliation(s)
- Elizabeth K Baker
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Faris N Al Gharaibeh
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Neonatology, Cincinnati Children's Hospital Medicine, Cincinnati, Ohio, United States
| | - Kevin Bove
- Division of Pathology, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | - Maria A Calvo-Garcia
- Radiology Department, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Amelle Shillington
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | | | - DonnaMaria E Cortezzo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Neonatology, Cincinnati Children's Hospital Medicine, Cincinnati, Ohio, United States
- Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Pain and Palliative Medicine, Cincinnati Children's Hospital Medicine, Cincinnati, Ohio, United States
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4
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Dalmas-Laurent AF, Bruneau B, Roux-Buisson N. Hyperthermie maligne de l’anesthésie. ANESTHÉSIE & RÉANIMATION 2023. [DOI: 10.1016/j.anrea.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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5
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Campiglio M, Dyrda A, Tuinte WE, Török E. Ca V1.1 Calcium Channel Signaling Complexes in Excitation-Contraction Coupling: Insights from Channelopathies. Handb Exp Pharmacol 2023; 279:3-39. [PMID: 36592225 DOI: 10.1007/164_2022_627] [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] [Indexed: 01/03/2023]
Abstract
In skeletal muscle, excitation-contraction (EC) coupling relies on the mechanical coupling between two ion channels: the L-type voltage-gated calcium channel (CaV1.1), located in the sarcolemma and functioning as the voltage sensor of EC coupling, and the ryanodine receptor 1 (RyR1), located on the sarcoplasmic reticulum serving as the calcium release channel. To this day, the molecular mechanism by which these two ion channels are linked remains elusive. However, recently, skeletal muscle EC coupling could be reconstituted in heterologous cells, revealing that only four proteins are essential for this process: CaV1.1, RyR1, and the cytosolic proteins CaVβ1a and STAC3. Due to the crucial role of these proteins in skeletal muscle EC coupling, any mutation that affects any one of these proteins can have devastating consequences, resulting in congenital myopathies and other pathologies.Here, we summarize the current knowledge concerning these four essential proteins and discuss the pathophysiology of the CaV1.1, RyR1, and STAC3-related skeletal muscle diseases with an emphasis on the molecular mechanisms. Being part of the same signalosome, mutations in different proteins often result in congenital myopathies with similar symptoms or even in the same disease.
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Affiliation(s)
- Marta Campiglio
- Institute of Physiology, Medical University Innsbruck, Innsbruck, Austria.
| | - Agnieszka Dyrda
- Institute of Physiology, Medical University Innsbruck, Innsbruck, Austria
| | - Wietske E Tuinte
- Institute of Physiology, Medical University Innsbruck, Innsbruck, Austria
| | - Enikő Török
- Institute of Physiology, Medical University Innsbruck, Innsbruck, Austria
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6
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O’Connor TN, van den Bersselaar LR, Chen YS, Nicolau S, Simon B, Huseth A, Todd JJ, Van Petegem F, Sarkozy A, Goldberg MF, Voermans NC, Dirksena RT. RYR-1-Related Diseases International Research Workshop: From Mechanisms to Treatments Pittsburgh, PA, U.S.A., 21-22 July 2022. J Neuromuscul Dis 2023; 10:135-154. [PMID: 36404556 PMCID: PMC10023165 DOI: 10.3233/jnd-221609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Thomas N. O’Connor
- Department of Pharmacology and Physiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Luuk R. van den Bersselaar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
- Malignant Hyperthermia Investigation Unit, Department of Anaesthesia, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Yu Seby Chen
- Department of Biochemistry and Molecular Biology, The Life Sciences Institute, The University of British Columbia, Vancouver, BC, Canada
| | - Stefan Nicolau
- Center for Gene Therapy, Nationwide Children’s Hospital, Columbus, OH, USA
| | | | | | - Joshua J. Todd
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Filip Van Petegem
- Department of Biochemistry and Molecular Biology, The Life Sciences Institute, The University of British Columbia, Vancouver, BC, Canada
| | - Anna Sarkozy
- The Dubowitz Neuromuscular Centre, Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | | | - Nicol C. Voermans
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert T. Dirksena
- Department of Pharmacology and Physiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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7
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van den Bersselaar LR, Heytens L, Silva HCA, Reimann J, Tasca G, Díaz‐Cambronero Ó, Løkken N, Hellblom A, Hopkins PM, Rueffert H, Bastian B, Vilchez JJ, Gillies R, Johannsen S, Veyckemans F, Muenster T, Klein A, Litman R, Jungbluth H, Riazi S, Voermans NC, Snoeck MMJ. European Neuromuscular Centre consensus statement on anaesthesia in patients with neuromuscular disorders. Eur J Neurol 2022; 29:3486-3507. [PMID: 35971866 PMCID: PMC9826444 DOI: 10.1111/ene.15526] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/05/2022] [Accepted: 08/11/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Patients with neuromuscular conditions are at increased risk of suffering perioperative complications related to anaesthesia. There is currently little specific anaesthetic guidance concerning these patients. Here, we present the European Neuromuscular Centre (ENMC) consensus statement on anaesthesia in patients with neuromuscular disorders as formulated during the 259th ENMC Workshop on Anaesthesia in Neuromuscular Disorders. METHODS International experts in the field of (paediatric) anaesthesia, neurology, and genetics were invited to participate in the ENMC workshop. A literature search was conducted in PubMed and Embase, the main findings of which were disseminated to the participants and presented during the workshop. Depending on specific expertise, participants presented the existing evidence and their expert opinion concerning anaesthetic management in six specific groups of myopathies and neuromuscular junction disorders. The consensus statement was prepared according to the AGREE II (Appraisal of Guidelines for Research & Evaluation) reporting checklist. The level of evidence has been adapted according to the SIGN (Scottish Intercollegiate Guidelines Network) grading system. The final consensus statement was subjected to a modified Delphi process. RESULTS A set of general recommendations valid for the anaesthetic management of patients with neuromuscular disorders in general have been formulated. Specific recommendations were formulated for (i) neuromuscular junction disorders, (ii) muscle channelopathies (nondystrophic myotonia and periodic paralysis), (iii) myotonic dystrophy (types 1 and 2), (iv) muscular dystrophies, (v) congenital myopathies and congenital dystrophies, and (vi) mitochondrial and metabolic myopathies. CONCLUSIONS This ENMC consensus statement summarizes the most important considerations for planning and performing anaesthesia in patients with neuromuscular disorders.
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Affiliation(s)
- Luuk R. van den Bersselaar
- Malignant Hyperthermia Investigation Unit, Department of AnaesthesiologyCanisius Wilhelmina Hospital NijmegenNijmegenThe Netherlands,Department of Neurology, Donders Institute for Brain, Cognition, and BehaviourRadboud University Medical CentreNijmegenThe Netherlands
| | - Luc Heytens
- Malignant Hyperthermia Research Unit, Departments of Anaesthesiology and NeurologyUniversity Hospital Antwerp, University of Antwerp and Born Bunge InstituteAntwerpBelgium
| | - Helga C. A. Silva
- Malignant Hyperthermia Unit, Department of Surgery, Discipline of Anaesthesia, Pain, and Intensive CareSão Paulo Federal UniversitySão PauloBrazil
| | - Jens Reimann
- Department of NeurologyUniversity of Bonn Medical CentreBonnGermany
| | - Giorgio Tasca
- UOC of NeurologyA. Gemelli University Polyclinic Foundation, Scientific Institute for Research and Health CareRomeItaly
| | - Óscar Díaz‐Cambronero
- Malignant Hyperthermia Unit, Department of AnaesthesiologyPerioperative Medicine Research Group, La Fe University and Polytechnic HospitalValenciaSpain
| | - Nicoline Løkken
- Copenhagen Neuromuscular CentreRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Anna Hellblom
- Department of Intensive and Perioperative CareSkåne University Hospital LundLundSweden
| | - Philip M. Hopkins
- Leeds Institute of Medical Research at St James'sUniversity of Leeds and Malignant Hyperthermia Investigation Unit, St James's University HospitalLeedsUK
| | - Henrik Rueffert
- Schkeuditz Helios Clinic, Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Intensive Care, Pain TherapyUniversity Hospital LeipzigLeipzigGermany
| | - Börge Bastian
- Schkeuditz Helios Clinic, Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology, Intensive Care, Pain TherapyUniversity Hospital LeipzigLeipzigGermany
| | - Juan Jesus Vilchez
- Neuromuscular Centre, La Fe Hospital UIP and ERN EURO‐NMDNeuromuscular Research Group at La Fe IIS and CIBERERValenciaSpain
| | - Robyn Gillies
- Malignant Hyperthermia Diagnostic Unit, Department of Anaesthesia and Pain ManagementRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Stephan Johannsen
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, Centre for Malignant HyperthermiaUniversity Hospital WürzburgWürzburgGermany
| | - Francis Veyckemans
- Paediatric Anaesthesia ClinicJeanne de Flandre Hospital, Lille University Hospital CentreLilleFrance
| | - Tino Muenster
- Department of Anaesthesia and Intensive Care MedicineHospital of the Order of St John of GodRegensburgGermany
| | - Andrea Klein
- Department of Paediatric NeurologyUniversity Children's Hospital UKBBBaselSwitzerland,Division of Neuropaediatrics, Development, and Rehabilitation, Department of Paediatrics, InselspitalBern University Hospital, University of BernBernSwitzerland
| | - Ron Litman
- Department of Anaesthesiology and Critical CareChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular ServiceEvelina's Children Hospital, Guy's and St Thomas' Hospital National Health Service Foundation TrustLondonUK,Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - Sheila Riazi
- Malignant Hyperthermia Investigation Unit, Department of Anaesthesiology and Pain MedicineUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Nicol C. Voermans
- Department of Neurology, Donders Institute for Brain, Cognition, and BehaviourRadboud University Medical CentreNijmegenThe Netherlands
| | - Marc M. J. Snoeck
- Malignant Hyperthermia Investigation Unit, Department of AnaesthesiologyCanisius Wilhelmina Hospital NijmegenNijmegenThe Netherlands
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8
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Rossi D, Catallo MR, Pierantozzi E, Sorrentino V. Mutations in proteins involved in E-C coupling and SOCE and congenital myopathies. J Gen Physiol 2022; 154:213407. [PMID: 35980353 PMCID: PMC9391951 DOI: 10.1085/jgp.202213115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022] Open
Abstract
In skeletal muscle, Ca2+ necessary for muscle contraction is stored and released from the sarcoplasmic reticulum (SR), a specialized form of endoplasmic reticulum through the mechanism known as excitation–contraction (E-C) coupling. Following activation of skeletal muscle contraction by the E-C coupling mechanism, replenishment of intracellular stores requires reuptake of cytosolic Ca2+ into the SR by the activity of SR Ca2+-ATPases, but also Ca2+ entry from the extracellular space, through a mechanism called store-operated calcium entry (SOCE). The fine orchestration of these processes requires several proteins, including Ca2+ channels, Ca2+ sensors, and Ca2+ buffers, as well as the active involvement of mitochondria. Mutations in genes coding for proteins participating in E-C coupling and SOCE are causative of several myopathies characterized by a wide spectrum of clinical phenotypes, a variety of histological features, and alterations in intracellular Ca2+ balance. This review summarizes current knowledge on these myopathies and discusses available knowledge on the pathogenic mechanisms of disease.
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Affiliation(s)
- Daniela Rossi
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy.,Interdepartmental Program of Molecular Diagnosis and Pathogenetic Mechanisms of Rare Genetic Diseases, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Maria Rosaria Catallo
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Enrico Pierantozzi
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Vincenzo Sorrentino
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy.,Interdepartmental Program of Molecular Diagnosis and Pathogenetic Mechanisms of Rare Genetic Diseases, Azienda Ospedaliero Universitaria Senese, Siena, Italy
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9
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Bachmann C, Franchini M, Van den Bersselaar LR, Kruijt N, Voermans NC, Bouman K, Kamsteeg EJ, Knop KC, Ruggiero L, Santoro L, Nevo Y, Wilmshurst J, Vissing J, Sinnreich M, Zorzato D, Muntoni F, Jungbluth H, Zorzato F, Treves S. Targeted transcript analysis in muscles from patients with genetically diverse congenital myopathies. Brain Commun 2022; 4:fcac224. [PMID: 36196089 PMCID: PMC9525005 DOI: 10.1093/braincomms/fcac224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 06/29/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital myopathies are a group of early onset muscle diseases of variable severity often with characteristic muscle biopsy findings and involvement of specific muscle types. The clinical diagnosis of patients typically relies on histopathological findings and is confirmed by genetic analysis. The most commonly mutated genes encode proteins involved in skeletal muscle excitation–contraction coupling, calcium regulation, sarcomeric proteins and thin–thick filament interaction. However, mutations in genes encoding proteins involved in other physiological functions (for example mutations in SELENON and MTM1, which encode for ubiquitously expressed proteins of low tissue specificity) have also been identified. This intriguing observation indicates that the presence of a genetic mutation impacts the expression of other genes whose product is important for skeletal muscle function. The aim of the present investigation was to verify if there are common changes in transcript and microRNA expression in muscles from patients with genetically heterogeneous congenital myopathies, focusing on genes encoding proteins involved in excitation–contraction coupling and calcium homeostasis, sarcomeric proteins, transcription factors and epigenetic enzymes. Our results identify RYR1, ATPB2B and miRNA-22 as common transcripts whose expression is decreased in muscles from congenital myopathy patients. The resulting protein deficiency may contribute to the muscle weakness observed in these patients. This study also provides information regarding potential biomarkers for monitoring disease progression and response to pharmacological treatments in patients with congenital myopathies.
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Affiliation(s)
- Christoph Bachmann
- Department of Biomedicine, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
- Department of Neurology, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
| | - Martina Franchini
- Department of Biomedicine, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
- Department of Neurology, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
| | - Luuk R Van den Bersselaar
- Department of Anesthesiology, Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital , Nijmegen , The Netherlands
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Nick Kruijt
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Nicol C Voermans
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Karlijn Bouman
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center , Nijmegen , The Netherlands
- Department of Pediatric Neurology, Donders Institute for Brain, Cognition and Behaviour, Amalia Children’s Hospital, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Erik-Jan Kamsteeg
- Department of Clinical Genetics, Radboud Institute for Molecular Life Sciences, Radboud University, Nijmegen Medical Centre , Nijmegen , The Netherlands
| | - Karl Christian Knop
- Muskelhistologisches Labor, Neurologische Abteilung, Asklepios Klinik St. Georg , Lohmuehlenstraße 5, Hamburg 20099 , Germany
| | - Lucia Ruggiero
- Dipartimento di Neuroscienze, Scienze Riproduttive ed Odontostomatologiche, Università degli Studi di Napoli Federico II , Via Pansini 5, Napoli 80131 , Italy
| | - Lucio Santoro
- Dipartimento di Neuroscienze, Scienze Riproduttive ed Odontostomatologiche, Università degli Studi di Napoli Federico II , Via Pansini 5, Napoli 80131 , Italy
| | - Yoram Nevo
- Institute of Neurology, Schneider Children’s Medical Center of Israel , Petah Tiqva , Israel
| | - Jo Wilmshurst
- Paediatric Neurology, Red Cross War Memorial Children’s Hospital, Neuroscience Institute, University of Cape Town , Cape Town , South Africa
| | - John Vissing
- Department of Neurology, section 8077, Rigshospitalet, University of Copenhagen , Blegdamsvej 9, Copenhagen DK-2100 , Denmark
| | - Michael Sinnreich
- Department of Biomedicine, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
- Department of Neurology, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
| | - Daniele Zorzato
- GKT School of Medical Education, King’s College London , Hodgkin Building, Newcomen Street, London SE1 1UL , UK
| | - Francesco Muntoni
- Dubowitz Neuromuscular Centre and MRC Centre for Neuromuscular Diseases, UCL, Institute of Child Health , London , UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre , London , UK
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina Children’s Hospital, St. Thomas’ Hospital , London , UK
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London , London , UK
- Randall Center for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine, King’s College , London , UK
| | - Francesco Zorzato
- Department of Biomedicine, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
- Department of Neurology, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
- Department of Life Science and Biotechnology, University of Ferrara , Via Borsari 46, Ferrara 44100 , Italy
| | - Susan Treves
- Department of Biomedicine, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
- Department of Neurology, Basel University Hospital , Hebelstrasse 20, Basel 4031 , Switzerland
- Department of Life Science and Biotechnology, University of Ferrara , Via Borsari 46, Ferrara 44100 , Italy
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10
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Artamonova IN, Zlotina AM, Ismagilova OR, Levko TA, Kolbina NY, Bryzzhin AV, Smorodin AP, Borodin AV, Mamaeva EA, Sukhotskaya AA, Kagantsov IM, Malysheva DA, Vasichkina ES, Pervunina TM, Petrova NA. Case Report: A novel PHOX2B p.Ala248_Ala266dup variant causing congenital central hypoventilation syndrome. Front Pediatr 2022; 10:1070303. [PMID: 36874254 PMCID: PMC9975566 DOI: 10.3389/fped.2022.1070303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/30/2022] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Congenital central hypoventilation syndrome (CCHS) is a rare disease characterized by central alveolar hypoventilation and impaired autonomic regulation, caused by pathogenic variants of PHOX2B gene. More than 90% of patients have a polyalanine repeat mutation (PARM) in the heterozygous state, characterized by the expansion of GCN repeats and an increase in the number of alanine repeats, so that genotypes 20/24-20/33 are formed (the normal genotype is 20/20). The remaining 10% of patients harbor non-PARMs. CASE DESCRIPTION We present a clinical case of a girl with a novel PHOX2B heterozygous genetic variant in the exon 3: NM_003924.4: c.735_791dup, p.Ala248_Ala266dup. The duplication includes 16 GCN (alanine) repeats and 3 adjacent amino acids. Both clinically healthy parents demonstrated a normal PHOX2B sequence. In addition, the girl has a variant of unknown significance in RYR1 gene and a variant of unknown significance in NKX2-5 gene. The child's phenotype is quite special. She needs ventilation during sleep, and has Hirschsprung's disease type I, arteriovenous malformation S4 of the left lung, ventricular and atrium septal defects, coronary right ventricular fistula, hemodynamically nonsignificant, episodes of sick sinus and atrioventricular dissociation with bradycardia, divergent alternating strabismus, and oculus uterque (both eyes) (OU) retinal angiopathy. Two episodes of hypoglycemic seizures were also registered. Severe pulmonary hypertension resolved after appropriate ventilation adjustment. Diagnostic odyssey was quite dramatic. CONCLUSION Detection of a novel PHOX2B variant expands the understanding of molecular mechanisms of CCHS and genotype-phenotype correlations.
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Affiliation(s)
- Irina N Artamonova
- Institute of Perinatology and Pediatrics, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Anna M Zlotina
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Olga R Ismagilova
- Federal State Budgetary Scientific Institution, Research Centre for Medical Genetics (RCMG), Moscow, Russia
| | - Tatyana A Levko
- Department of Pediatric and Medical Rehabilitation, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Natalia Yu Kolbina
- Department of Pediatric and Medical Rehabilitation, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Aleksandr V Bryzzhin
- Pediatric Anesthesiology and Intensive Care Unit, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Andrey P Smorodin
- Pediatric Surgery Anesthesiology and Intensive Care Unit Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Alexandr V Borodin
- World-Class Research Centre for Personalized Medicine, Research Centre of Unknown, Rare and Genetically Determined Diseases, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Ekaterina A Mamaeva
- Institute of Perinatology and Pediatrics, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Anna A Sukhotskaya
- Department of Pediatric Surgery for Congenital Malformations, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Ilya M Kagantsov
- Department of Pediatric Surgery for Congenital Malformations, Institute of Perinatology and Pediatrics, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Daria A Malysheva
- Department of Pediatric Surgery for Congenital Malformations, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Elena S Vasichkina
- World-Class Research Centre for Personalized Medicine, Research Centre of Unknown, Rare and Genetically Determined Diseases, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Tatiana M Pervunina
- Institute of Perinatology and Pediatrics, World-Class Research Centre for Personalized Medicine, Research Centre of Unknown, Rare and Genetically Determined Diseases, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Natalia A Petrova
- World-Class Research Centre for Personalized Medicine, Research Centre of Unknown, Rare and Genetically Determined Diseases, Institute of Perinatology and Pediatrics, Almazov National Medical Research Centre, Saint-Petersburg, Russia
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11
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Baban A, Lodato V, Parlapiano G, di Mambro C, Adorisio R, Bertini ES, Dionisi-Vici C, Drago F, Martinelli D. Myocardial and Arrhythmic Spectrum of Neuromuscular Disorders in Children. Biomolecules 2021; 11:1578. [PMID: 34827576 PMCID: PMC8615674 DOI: 10.3390/biom11111578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/02/2021] [Accepted: 10/14/2021] [Indexed: 12/30/2022] Open
Abstract
Neuromuscular disorders (NMDs) are highly heterogenous from both an etiological and clinical point of view. Their signs and symptoms are often multisystemic, with frequent cardiac involvement. In fact, childhood onset forms can predispose a person to various progressive cardiac abnormalities including cardiomyopathies (CMPs), valvulopathies, atrioventricular conduction defects (AVCD), supraventricular tachycardia (SVT) and ventricular arrhythmias (VA). In this review, we selected and described five specific NMDs: Friedreich's Ataxia (FRDA), congenital and childhood forms of Myotonic Dystrophy type 1 (DM1), Kearns Sayre Syndrome (KSS), Ryanodine receptor type 1-related myopathies (RYR1-RM) and Laminopathies. These changes are widely investigated in adults but less researched in children. We focused on these specific topics due their relative frequency and their potential unexpected cardiac manifestations in children. Moreover these conditions present different inheritance patterns and mechanisms of action. We decided not to discuss Duchenne and Becker muscular dystrophies due to extensive work regarding the cardiac aspects in children. For each described NMD, we focused on the possible cardiac manifestations such as different types of CMPs (dilated-DCM, hypertrophic-HCM, restrictive-RCM or left ventricular non compaction-LVNC), structural heart abnormalities (including valvulopathies), and progressive heart rhythm changes (AVCD, SVT, VA). We describe the current management strategies for these conditions. We underline the importance, especially for children, of a serial multidisciplinary personalized approach and the need for periodic surveillance by a dedicated heart team. This is largely due to the fact that in children, the diagnosis of certain NMDs might be overlooked and the cardiac aspect can provide signs of their presence even prior to overt neurological diagnosis.
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Affiliation(s)
- Anwar Baban
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplantation, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (C.d.M.); (R.A.); (F.D.)
| | - Valentina Lodato
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplantation, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (C.d.M.); (R.A.); (F.D.)
| | - Giovanni Parlapiano
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unit, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy;
| | - Corrado di Mambro
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplantation, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (C.d.M.); (R.A.); (F.D.)
| | - Rachele Adorisio
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplantation, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (C.d.M.); (R.A.); (F.D.)
| | - Enrico Silvio Bertini
- The European Reference Network for Neuromuscular Disorders (ERN NMD), Unit of Neuromuscular and Neurodegenerative Disorders, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00146 Rome, Italy;
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (C.D.-V.); (D.M.)
| | - Fabrizio Drago
- The European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Department of Pediatric Cardiology and Cardiac Surgery, Heart and Lung Transplantation, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (V.L.); (C.d.M.); (R.A.); (F.D.)
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children Hospital and Research Institute, IRCCS, 00165 Rome, Italy; (C.D.-V.); (D.M.)
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12
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Capella-Peris C, Cosgrove MM, Chrismer IC, Razaqyar MS, Elliott JS, Kuo A, Emile-Backer M, Meilleur KG. Understanding Symptoms in RYR1-Related Myopathies: A Mixed-Methods Analysis Based on Participants' Experience. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 13:423-434. [PMID: 32329019 DOI: 10.1007/s40271-020-00418-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In rare diseases such as ryanodine receptor 1-related myopathies (RYR1-RM), health-related quality of life (HRQoL) measures are critically important so clinicians and researchers can better understand what symptoms are most important to participants, with the ultimate goal of finding tangible solutions for them. OBJECTIVES The main objective of this study was to characterize symptoms in individuals with RYR1-RM to inform future research. A secondary objective of this study was to analyze positive and negative sentiments regarding symptoms and treatment effects post N-acetylcysteine (NAC) administration in individuals with RYR1-RM. METHODS The study used a mixed-methods design applying methodological triangulation. Qualitative data were collected via semi-structured interviews at three visits to characterize symptoms in individuals with RYR1-RM and to analyze treatment effects. Qualitative data were then transformed into quantitative results to measure the frequency with which each symptom was mentioned by participants. RESULTS A total of 12 symptoms were identified as areas of interest to participants with RYR1-RM, highlighting fatigue and weakness as key symptoms. Data transformation categorized more than 1000 citations, reporting a greater number of positive comments for postintervention interviews than for baseline and preintervention visits and that NAC group participants stated more positive comments regarding treatment effect than did the placebo group. CONCLUSIONS We present a comprehensive characterization of symptoms in RYR1-RM and how those symptoms influence HRQoL. Furthermore, the introduction of mixed methods may be a valuable way to better understand patient-centered data in rare diseases to support affected individuals in coping with their symptoms.
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Affiliation(s)
- Carlos Capella-Peris
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA.
| | - Mary M Cosgrove
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Irene C Chrismer
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - M Sonia Razaqyar
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Jeffrey S Elliott
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Anna Kuo
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Magalie Emile-Backer
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
| | - Katherine G Meilleur
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Building 60, Room 254, Bethesda, MD, 20892, USA
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13
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Mauri E, Piga D, Govoni A, Brusa R, Pagliarani S, Ripolone M, Dilena R, Cinnante C, Sciacco M, Cassandrini D, Nigro V, Bresolin N, Corti S, Comi GP, Magri F. Early Findings in Neonatal Cases of RYR1-Related Congenital Myopathies. Front Neurol 2021; 12:664618. [PMID: 34262519 PMCID: PMC8273285 DOI: 10.3389/fneur.2021.664618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/21/2021] [Indexed: 12/03/2022] Open
Abstract
Ryanodine receptor type 1-related congenital myopathies are the most represented subgroup among congenital myopathies (CMs), typically presenting a central core or multiminicore muscle histopathology and high clinical heterogeneity. We evaluated a cohort of patients affected with Ryanodine receptor type 1-related congenital myopathy (RYR1-RCM), focusing on four patients who showed a severe congenital phenotype and underwent a comprehensive characterization at few months of life. To date there are few reports on precocious instrumental assessment. In two out of the four patients, a muscle biopsy was performed in the first days of life (day 5 and 37, respectively) and electron microscopy was carried out in two patients detecting typical features of congenital myopathy. Two patients underwent brain MRI in the first months of life (15 days and 2 months, respectively), one also a fetal brain MRI. In three children electromyography was performed in the first week of life and neurogenic signs were excluded. Muscle MRI obtained within the first years of life showed a typical pattern of RYR1-CM. The diagnosis was confirmed through genetic analysis in three out of four cases using Next Generation Sequencing (NGS) panels. The development of a correct and rapid diagnosis is a priority and may lead to prompt medical management and helps optimize inclusion in future clinical trials.
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Affiliation(s)
- Eleonora Mauri
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Piga
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Govoni
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberta Brusa
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Serena Pagliarani
- Neuroscience Section, Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Milan, Italy
| | - Michela Ripolone
- Neuromuscular and Rare Diseases Unit, Istituto di Ricerca e Cura a Carattere Scientifico Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Robertino Dilena
- Neuropathophysiology Unit, Istituto di Ricerca e Cura a Carattere Scientifico Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Cinnante
- Neuroradiology Unit, Istituto di Ricerca e Cura a Carattere Scientifico Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Monica Sciacco
- Neuromuscular and Rare Diseases Unit, Istituto di Ricerca e Cura a Carattere Scientifico Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Denise Cassandrini
- Molecular Medicine, Istituto di Ricerca e Cura a Carattere Scientifico Fondazione Stella Maris, Pisa, Italy
| | - Vincenzo Nigro
- "Luigi Vanvitelli" University and Telethon Institute of Genetics and Medicine (TIGEM), Naples, Italy
| | - Nereo Bresolin
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Neuroscience Section, Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Milan, Italy
| | - Stefania Corti
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Neuroscience Section, Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Milan, Italy
| | - Giacomo P Comi
- Neuroscience Section, Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Milan, Italy.,Neuromuscular and Rare Diseases Unit, Istituto di Ricerca e Cura a Carattere Scientifico Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Magri
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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14
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Maggi L, Bonanno S, Altamura C, Desaphy JF. Ion Channel Gene Mutations Causing Skeletal Muscle Disorders: Pathomechanisms and Opportunities for Therapy. Cells 2021; 10:cells10061521. [PMID: 34208776 PMCID: PMC8234207 DOI: 10.3390/cells10061521] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/03/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023] Open
Abstract
Skeletal muscle ion channelopathies (SMICs) are a large heterogeneous group of rare genetic disorders caused by mutations in genes encoding ion channel subunits in the skeletal muscle mainly characterized by myotonia or periodic paralysis, potentially resulting in long-term disabilities. However, with the development of new molecular technologies, new genes and new phenotypes, including progressive myopathies, have been recently discovered, markedly increasing the complexity in the field. In this regard, new advances in SMICs show a less conventional role of ion channels in muscle cell division, proliferation, differentiation, and survival. Hence, SMICs represent an expanding and exciting field. Here, we review current knowledge of SMICs, with a description of their clinical phenotypes, cellular and molecular pathomechanisms, and available treatments.
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Affiliation(s)
- Lorenzo Maggi
- Neuroimmunology and Neuromuscular Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
- Correspondence:
| | - Silvia Bonanno
- Neuroimmunology and Neuromuscular Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy;
| | - Concetta Altamura
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, 70124 Bari, Italy; (C.A.); (J.-F.D.)
| | - Jean-François Desaphy
- Department of Biomedical Sciences and Human Oncology, School of Medicine, University of Bari Aldo Moro, 70124 Bari, Italy; (C.A.); (J.-F.D.)
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15
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Savarese M, Sarparanta J, Vihola A, Jonson PH, Johari M, Rusanen S, Hackman P, Udd B. Panorama of the distal myopathies. ACTA MYOLOGICA : MYOPATHIES AND CARDIOMYOPATHIES : OFFICIAL JOURNAL OF THE MEDITERRANEAN SOCIETY OF MYOLOGY 2020; 39:245-265. [PMID: 33458580 PMCID: PMC7783427 DOI: 10.36185/2532-1900-028] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 12/15/2022]
Abstract
Distal myopathies are genetic primary muscle disorders with a prominent weakness at onset in hands and/or feet. The age of onset (from early childhood to adulthood), the distribution of muscle weakness (upper versus lower limbs) and the histological findings (ranging from nonspecific myopathic changes to myofibrillar disarrays and rimmed vacuoles) are extremely variable. However, despite being characterized by a wide clinical and genetic heterogeneity, the distal myopathies are a category of muscular dystrophies: genetic diseases with progressive loss of muscle fibers. Myopathic congenital arthrogryposis is also a form of distal myopathy usually caused by focal amyoplasia. Massive parallel sequencing has further expanded the long list of genes associated with a distal myopathy, and contributed identifying as distal myopathy-causative rare variants in genes more often related with other skeletal or cardiac muscle diseases. Currently, almost 20 genes (ACTN2, CAV3, CRYAB, DNAJB6, DNM2, FLNC, HNRNPA1, HSPB8, KHLH9, LDB3, MATR3, MB, MYOT, PLIN4, TIA1, VCP, NOTCH2NLC, LRP12, GIPS1) have been associated with an autosomal dominant form of distal myopathy. Pathogenic changes in four genes (ADSSL, ANO5, DYSF, GNE) cause an autosomal recessive form; and disease-causing variants in five genes (DES, MYH7, NEB, RYR1 and TTN) result either in a dominant or in a recessive distal myopathy. Finally, a digenic mechanism, underlying a Welander-like form of distal myopathy, has been recently elucidated. Rare pathogenic mutations in SQSTM1, previously identified with a bone disease (Paget disease), unexpectedly cause a distal myopathy when combined with a common polymorphism in TIA1. The present review aims at describing the genetic basis of distal myopathy and at summarizing the clinical features of the different forms described so far.
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Affiliation(s)
- Marco Savarese
- Folkhälsan Research Center, Helsinki, Finland
- Department of Medical Genetics, Medicum, University of Helsinki, Helsinki, Finland
| | - Jaakko Sarparanta
- Folkhälsan Research Center, Helsinki, Finland
- Department of Medical Genetics, Medicum, University of Helsinki, Helsinki, Finland
| | - Anna Vihola
- Folkhälsan Research Center, Helsinki, Finland
- Department of Medical Genetics, Medicum, University of Helsinki, Helsinki, Finland
- Neuromuscular Research Center, Department of Genetics, Fimlab Laboratories, Tampere, Finland
| | - Per Harald Jonson
- Folkhälsan Research Center, Helsinki, Finland
- Department of Medical Genetics, Medicum, University of Helsinki, Helsinki, Finland
| | - Mridul Johari
- Folkhälsan Research Center, Helsinki, Finland
- Department of Medical Genetics, Medicum, University of Helsinki, Helsinki, Finland
| | - Salla Rusanen
- Folkhälsan Research Center, Helsinki, Finland
- Department of Medical Genetics, Medicum, University of Helsinki, Helsinki, Finland
| | - Peter Hackman
- Folkhälsan Research Center, Helsinki, Finland
- Department of Medical Genetics, Medicum, University of Helsinki, Helsinki, Finland
| | - Bjarne Udd
- Folkhälsan Research Center, Helsinki, Finland
- Department of Medical Genetics, Medicum, University of Helsinki, Helsinki, Finland
- Department of Neurology, Vaasa Central Hospital, Vaasa, Finland
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16
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Lawal TA, Todd JJ, Witherspoon JW, Bönnemann CG, Dowling JJ, Hamilton SL, Meilleur KG, Dirksen RT. Ryanodine receptor 1-related disorders: an historical perspective and proposal for a unified nomenclature. Skelet Muscle 2020; 10:32. [PMID: 33190635 PMCID: PMC7667763 DOI: 10.1186/s13395-020-00243-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/18/2020] [Indexed: 12/14/2022] Open
Abstract
The RYR1 gene, which encodes the sarcoplasmic reticulum calcium release channel or type 1 ryanodine receptor (RyR1) of skeletal muscle, was sequenced in 1988 and RYR1 variations that impair calcium homeostasis and increase susceptibility to malignant hyperthermia were first identified in 1991. Since then, RYR1-related myopathies (RYR1-RM) have been described as rare, histopathologically and clinically heterogeneous, and slowly progressive neuromuscular disorders. RYR1 variants can lead to dysfunctional RyR1-mediated calcium release, malignant hyperthermia susceptibility, elevated oxidative stress, deleterious post-translational modifications, and decreased RyR1 expression. RYR1-RM-affected individuals can present with delayed motor milestones, contractures, scoliosis, ophthalmoplegia, and respiratory insufficiency. Historically, RYR1-RM-affected individuals were diagnosed based on morphologic features observed in muscle biopsies including central cores, cores and rods, central nuclei, fiber type disproportion, and multi-minicores. However, these histopathologic features are not always specific to RYR1-RM and often change over time. As additional phenotypes were associated with RYR1 variations (including King-Denborough syndrome, exercise-induced rhabdomyolysis, lethal multiple pterygium syndrome, adult-onset distal myopathy, atypical periodic paralysis with or without myalgia, mild calf-predominant myopathy, and dusty core disease) the overlap among diagnostic categories is ever increasing. With the continuing emergence of new clinical subtypes along the RYR1 disease spectrum and reports of adult-onset phenotypes, nuanced nomenclatures have been reported (RYR1- [related, related congenital, congenital] myopathies). In this narrative review, we provide historical highlights of RYR1 research, accounts of the main diagnostic disease subtypes and propose RYR1-related disorders (RYR1-RD) as a unified nomenclature to describe this complex and evolving disease spectrum.
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Affiliation(s)
- Tokunbor A Lawal
- Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA.
| | - Joshua J Todd
- Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Jessica W Witherspoon
- Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Carsten G Bönnemann
- Neurogenetics Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - James J Dowling
- Departments of Paediatrics and Molecular Genetics, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Susan L Hamilton
- Molecular Physiology & Biophysics, Baylor College of Medicine, Houston, TX, USA
| | - Katherine G Meilleur
- Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Robert T Dirksen
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, NY, USA
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17
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Noorian S, Khonsari NM, Savad S, Hakak-Zargar B, Voth T, Kabir K. Whole-Exome Sequencing in Idiopathic Short Stature: Rare Mutations Affecting Growth. J Pediatr Genet 2020; 10:284-291. [PMID: 34849273 DOI: 10.1055/s-0040-1716400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/26/2020] [Indexed: 12/24/2022]
Abstract
Idiopathic short stature (ISS) is a common diagnosis of exclusion in patients with short stature (SS). In this article, we aimed to identify the genetic causes of SS in patients with ISS and investigate treatment options. Fourteen children with diagnosis of ISS were identified, and whole-exome sequencing (WES) was subsequently conducted on blood-derived DNA. Five patients were correctly diagnosed with ISS and four had rare mutations that have not been previously reported. Four patients had mutations known to cause SS and one had a mutation that was known not to affect height. WES can help identify rare mutations implicated in ISS.
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Affiliation(s)
- Shahab Noorian
- Department of Pediatrics, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | | | | | - Benyamin Hakak-Zargar
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Tessa Voth
- Department of Biomedical Physiology and Kinesiology, Faculty of Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Koroush Kabir
- Department of Community Medicine and Epidemiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
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18
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Capella-Peris C, Cosgrove MM, Chrismer IC, Emile-Backer M, Razaqyar MS, Elliott JS, Kuo A, Wakim PG, Meilleur KG. Mixed methods analysis of Health-Related Quality of Life in ambulant individuals affected with RYR1-related myopathies pre-post-N-acetylcysteine therapy. Qual Life Res 2020; 29:1641-1653. [PMID: 32040747 PMCID: PMC7728916 DOI: 10.1007/s11136-020-02428-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To characterize Health-Related Quality of Life (HRQoL) in ambulant individuals with RYR1-RM and to determine if a qualitative PRO tool (subjective self-assessment) complements PROMIS and Neuro-QoL scales to detect changes in HRQoL in ambulant individuals with RYR1-RM post N-acetylcysteine (NAC) treatment. METHODS The study used a mixed methods research (MMR) design applying methodological triangulation. Qualitative data were collected via semi-structured interviews using open-ended questions. Quantitative data were gathered through PROMIS and Neuro-QoL instruments. Additionally, qualitative data were transformed into quantitative data for subjective self-assessment and frequency analyses. RESULTS Qualitative results identified five domains and 33 subdomains as areas of interest. The most valuable were the importance of social impacts, the development of several coping strategies, both physical and psychological, and the identification of fatigue and weakness as key symptoms. Data transformation then categorized more than 3100 citations on frequency analyses, globally and by domain, visit, and participant. Regarding quantitative results, there was no clear evidence that any of the three PRO tools captured positive changes as a result of NAC treatment. CONCLUSION Qualitative results showed a comprehensive characterization of HRQoL in this population based on a symptom/patient-centered approach. These findings will inform future studies. Furthermore, given the similar findings across our multiple methods and endpoints, the introduction of MMR may be a valuable, complementary approach to clinical trials. MMR may be especially useful to incorporate in order to address and follow the FDA's guidance and prioritization on the inclusion of affected individuals' perspectives in clinical trials.
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Affiliation(s)
- Carlos Capella-Peris
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA.
| | - Mary M Cosgrove
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Irene C Chrismer
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Magalie Emile-Backer
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - M Sonia Razaqyar
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey S Elliott
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Anna Kuo
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Paul G Wakim
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Katherine G Meilleur
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
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19
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Rodríguez Cruz PM, Cossins J, Estephan EDP, Munell F, Selby K, Hirano M, Maroofin R, Mehrjardi MYV, Chow G, Carr A, Manzur A, Robb S, Munot P, Wei Liu W, Banka S, Fraser H, De Goede C, Zanoteli E, Conti Reed U, Sage A, Gratacos M, Macaya A, Dusl M, Senderek J, Töpf A, Hofer M, Knight R, Ramdas S, Jayawant S, Lochmüller H, Palace J, Beeson D. The clinical spectrum of the congenital myasthenic syndrome resulting from COL13A1 mutations. Brain 2020; 142:1547-1560. [PMID: 31081514 PMCID: PMC6752227 DOI: 10.1093/brain/awz107] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/08/2019] [Accepted: 02/22/2019] [Indexed: 02/02/2023] Open
Abstract
Next generation sequencing techniques were recently used to show mutations in COL13A1 cause synaptic basal lamina-associated congenital myasthenic syndrome type 19. Animal studies showed COL13A1, a synaptic extracellular-matrix protein, is involved in the formation and maintenance of the neuromuscular synapse that appears independent of the Agrin-LRP4-MuSK-DOK7 acetylcholine receptor clustering pathway. Here, we report the phenotypic spectrum of 16 patients from 11 kinships harbouring homozygous or heteroallelic mutations in COL13A1. Clinical presentation was mostly at birth with hypotonia and breathing and feeding difficulties often requiring ventilation and artificial feeding. Respiratory crisis related to recurrent apnoeas, sometimes triggered by chest infections, were common early in life but resolved over time. The predominant pattern of muscle weakness included bilateral ptosis (non-fatigable in adulthood), myopathic facies and marked axial weakness, especially of neck flexion, while limb muscles were less involved. Other features included facial dysmorphism, skeletal abnormalities and mild learning difficulties. All patients tested had results consistent with abnormal neuromuscular transmission. Muscle biopsies were within normal limits or showed non-specific changes. Muscle MRI and serum creatine kinase levels were normal. In keeping with COL13A1 mutations affecting both synaptic structure and presynaptic function, treatment with 3,4-diaminopyridine and salbutamol resulted in motor and respiratory function improvement. In non-treated cases, disease severity and muscle strength improved gradually over time and several adults recovered normal muscle strength in the limbs. In summary, patients with COL13A1 mutations present mostly with severe early-onset myasthenic syndrome with feeding and breathing difficulties. Axial weakness is greater than limb weakness. Disease course improves gradually over time, which could be consistent with the less prominent role of COL13A1 once the neuromuscular junction is mature. This report emphasizes the role of collagens at the human muscle endplate and should facilitate the recognition of this disorder, which can benefit from pharmacological treatment.
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Affiliation(s)
- Pedro M Rodríguez Cruz
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK.,Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Judith Cossins
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Eduardo de Paula Estephan
- Departamento de Neurologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Francina Munell
- Neuromuscular disorders Group, Child Neurology Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Kathryn Selby
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Michio Hirano
- Department of Neurology, H. Houston Merritt Neuromuscular Research Center, Columbia University Medical Center, New York, NY, USA
| | - Reza Maroofin
- Molecular and Clinical Sciences Institute, St. George's, University of London, Cranmer Terrace, London, UK
| | | | - Gabriel Chow
- Department of Paediatric Neurology, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, UK
| | - Aisling Carr
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Adnan Manzur
- Dubowitz Neuromuscular Centre and MRC Centre for Neuromuscular Diseases, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Stephanie Robb
- Dubowitz Neuromuscular Centre and MRC Centre for Neuromuscular Diseases, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Pinki Munot
- Dubowitz Neuromuscular Centre and MRC Centre for Neuromuscular Diseases, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Wei Wei Liu
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Siddharth Banka
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Health Innovation Manchester, Manchester, UK
| | - Harry Fraser
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Health Innovation Manchester, Manchester, UK
| | | | - Edmar Zanoteli
- Departamento de Neurologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Umbertina Conti Reed
- Departamento de Neurologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Abigail Sage
- Department of Neurology, H. Houston Merritt Neuromuscular Research Center, Columbia University Medical Center, New York, NY, USA
| | - Margarida Gratacos
- Department of Clinical Neurophysiology, Hospital Universitari Vall d'Hebron, Barcelona Spain
| | - Alfons Macaya
- Neuromuscular disorders Group, Child Neurology Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Marina Dusl
- Friedrich-Baur-Institute at the Department of Neurology, University Hospital LMU Munich, Munich, Germany
| | - Jan Senderek
- Friedrich-Baur-Institute at the Department of Neurology, University Hospital LMU Munich, Munich, Germany
| | - Ana Töpf
- Institute of Genetic Medicine, Central Parkway, Newcastle upon Tyne, UK
| | - Monika Hofer
- Department of Neuropathology, John Radcliffe Hospital NHS Foundation Trust, Oxford, UK
| | - Ravi Knight
- Department of Clinical Neurophysiology, John Radcliffe Hospital NHS Foundation Trust, Oxford, UK
| | - Sithara Ramdas
- Department of Paediatric Neurology, John Radcliffe Hospital NHS Foundation Trust, Oxford, UK
| | - Sandeep Jayawant
- Department of Paediatric Neurology, John Radcliffe Hospital NHS Foundation Trust, Oxford, UK
| | - Hans Lochmüller
- Department of Neuropediatrics and Muscle Disorders, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany.,Centro Nacional de Análisis Genómico (CNAG-CRG), Center for Genomic Regulation, Barcelona Institute of Science and Technology (BIST), Barcelona, Spain.,Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Canada.,Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - David Beeson
- Neurosciences Group, Nuffield Department of Clinical Neurosciences, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
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20
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Brennan S, Garcia-Castañeda M, Michelucci A, Sabha N, Malik S, Groom L, Wei LaPierre L, Dowling JJ, Dirksen RT. Mouse model of severe recessive RYR1-related myopathy. Hum Mol Genet 2020; 28:3024-3036. [PMID: 31107960 DOI: 10.1093/hmg/ddz105] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/07/2019] [Accepted: 05/13/2019] [Indexed: 12/16/2022] Open
Abstract
Ryanodine receptor type I (RYR1)-related myopathies (RYR1 RM) are a clinically and histopathologically heterogeneous group of conditions that represent the most common subtype of childhood onset non-dystrophic muscle disorders. There are no treatments for this severe group of diseases. A major barrier to therapy development is the lack of an animal model that mirrors the clinical severity of pediatric cases of the disease. To address this, we used CRISPR/Cas9 gene editing to generate a novel recessive mouse model of RYR1 RM. This mouse (Ryr1TM/Indel) possesses a patient-relevant point mutation (T4706M) engineered into 1 allele and a 16 base pair frameshift deletion engineered into the second allele. Ryr1TM/Indel mice exhibit an overt phenotype beginning at 14 days of age that consists of reduced body/muscle mass and myofibre hypotrophy. Ryr1TM/Indel mice become progressively inactive from that point onward and die at a median age of 42 days. Histopathological assessment shows myofibre hypotrophy, increased central nuclei and decreased triad number but no clear evidence of metabolic cores. Biochemical analysis reveals a marked decrease in RYR1 protein levels (20% of normal) as compared to only a 50% decrease in transcript. Functional studies at end stage show significantly reduced electrically evoked Ca2+ release and force production. In summary, Ryr1TM/Indel mice exhibit a post-natal lethal recessive form of RYR1 RM that pheno-copies the severe congenital clinical presentation seen in a subgroup of RYR1 RM children. Thus, Ryr1TM/Indel mice represent a powerful model for both establishing the pathomechanisms of recessive RYR1 RM and pre-clinical testing of therapies for efficacy.
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Affiliation(s)
- Stephanie Brennan
- Program for Genetics and Genome Biology, Hospital for Sick Children, 686 Bay St, Toronto, Ontario, M5G 0A4, Canada.,Department of Molecular Genetics, University of Toronto, 686 Bay St, Toronto, Ontario, M5G 0A4, Canada
| | - Maricela Garcia-Castañeda
- Department of Pharmacology and Physiology, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642 USA
| | - Antonio Michelucci
- Department of Pharmacology and Physiology, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642 USA
| | - Nesrin Sabha
- Program for Genetics and Genome Biology, Hospital for Sick Children, 686 Bay St, Toronto, Ontario, M5G 0A4, Canada
| | - Sundeep Malik
- Department of Pharmacology and Physiology, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642 USA
| | - Linda Groom
- Department of Pharmacology and Physiology, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642 USA
| | - Lan Wei LaPierre
- Department of Pharmacology and Physiology, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642 USA
| | - James J Dowling
- Program for Genetics and Genome Biology, Hospital for Sick Children, 686 Bay St, Toronto, Ontario, M5G 0A4, Canada.,Department of Molecular Genetics, University of Toronto, 686 Bay St, Toronto, Ontario, M5G 0A4, Canada.,Division of Neurology, Hospital for Sick Children, 686 Bay St, Toronto, Ontario, M5G 0A4, Canada
| | - Robert T Dirksen
- Department of Pharmacology and Physiology, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642 USA
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21
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Schartner V, Laporte J, Böhm J. Abnormal Excitation-Contraction Coupling and Calcium Homeostasis in Myopathies and Cardiomyopathies. J Neuromuscul Dis 2020; 6:289-305. [PMID: 31356215 DOI: 10.3233/jnd-180314] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Muscle contraction requires specialized membrane structures with precise geometry and relies on the concerted interplay of electrical stimulation and Ca2+ release, known as excitation-contraction coupling (ECC). The membrane structure hosting ECC is called triad in skeletal muscle and dyad in cardiac muscle, and structural or functional defects of triads and dyads have been observed in a variety of myopathies and cardiomyopathies. Based on their function, the proteins localized at the triad/dyad can be classified into three molecular pathways: the Ca2+ release complex (CRC), store-operated Ca2+ entry (SOCE), and membrane remodeling. All three are mechanistically linked, and consequently, aberrations in any of these pathways cause similar disease entities. This review provides an overview of the clinical and genetic spectrum of triad and dyad defects with a main focus of attention on the underlying pathomechanisms.
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Affiliation(s)
- Vanessa Schartner
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Illkirch, France.,INSERM U1258, Illkirch, France.,CNRS UMR7104, Illkirch, France.,Strasbourg University, Illkirch, France
| | - Jocelyn Laporte
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Illkirch, France.,INSERM U1258, Illkirch, France.,CNRS UMR7104, Illkirch, France.,Strasbourg University, Illkirch, France
| | - Johann Böhm
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Illkirch, France.,INSERM U1258, Illkirch, France.,CNRS UMR7104, Illkirch, France.,Strasbourg University, Illkirch, France
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22
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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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23
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Schiemann AH, Roesl C, Pollock N, Langton E, Bulger T, Stowell KM. Identification and Functional Analysis of RYR1 Variants in a Family with a Suspected Myopathy and Associated Malignant Hyperthermia. J Neuromuscul Dis 2020; 7:51-60. [PMID: 31903994 DOI: 10.3233/jnd-190430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The ryanodine receptor 1 (RyR1) is a major skeletal muscle calcium release channel located in the sarcoplasmic reticulum and involved in excitation-contraction coupling. Variants in the gene encoding RyR1 have been linked to a range of neuromuscular disorders including myopathies and malignant hyperthermia (MH). OBJECTIVE We have identified three RYR1 variants (c.1983 G>A, p.Trp661*; c.7025A>G, p.Asn2342Ser and c.2447 C>T, p.Pro816Leu) in a family with a suspected myopathy and associated malignant hyperthermia susceptibility. We used calcium release assays to functionally characterise these variants in a recombinant system. METHODS Site-directed mutagenesis was used to introduce each variant separately into the human RYR1 cDNA. HEK293-T cells were transfected with the recombinant constructs and calcium release assays were carried out using 4-chloro-m-cresol (4-CmC) as the RyR1 agonist to investigate the functional consequences of each variant. RESULTS RYR1 c.1983 G>A, p.Trp661* resulted in a non-functional channel, c.7025A>G, p.Asn2342Ser in a hypersensitive channel and c.2447 C>T, p.Pro816Leu in a hypersensitive channel at higher concentrations of 4-CmC. CONCLUSIONS The p.Trp661* RYR1 variant should be considered as a risk factor for myopathies. The p.Asn2342Ser RYR1 variant, when expressed as a compound heterozygote with a nonsense mutation on the second allele, is likely to result in MH-susceptibility. The role of the p.Pro816Leu variant in MH remains unclear.
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Affiliation(s)
- Anja H Schiemann
- School of Fundamental Sciences, Massey University, Manawatu, New Zealand
| | - Cornelia Roesl
- School of Fundamental Sciences, Massey University, Manawatu, New Zealand.,Present address: LifeArc, Nine, Edinburgh BioQuarter, Edinburgh, United Kingdom
| | - Neil Pollock
- Department of Anaesthesia and Intensive Care, Palmerston North Hospital, Manawatu, New Zealand.,Now retired
| | | | - Terasa Bulger
- Department of Anaesthesia and Intensive Care, Palmerston North Hospital, Manawatu, New Zealand
| | - Kathryn M Stowell
- School of Fundamental Sciences, Massey University, Manawatu, New Zealand
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24
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Chagovetz AA, Klatt Shaw D, Ritchie E, Hoshijima K, Grunwald DJ. Interactions among ryanodine receptor isotypes contribute to muscle fiber type development and function. Dis Model Mech 2019; 13:dmm.038844. [PMID: 31383689 PMCID: PMC6906632 DOI: 10.1242/dmm.038844] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/17/2019] [Indexed: 12/14/2022] Open
Abstract
Mutations affecting ryanodine receptor (RyR) calcium release channels commonly underlie congenital myopathies. Although these channels are known principally for their essential roles in muscle contractility, mutations in the human RYR1 gene result in a broad spectrum of phenotypes, including muscle weakness, altered proportions of fiber types, anomalous muscle fibers with cores or centrally placed nuclei, and dysmorphic craniofacial features. Currently, it is unknown which phenotypes directly reflect requirements for RyRs and which result secondarily to aberrant muscle function. To identify biological processes requiring RyR function, skeletal muscle development was analyzed in zebrafish embryos harboring protein-null mutations. RyR channels contribute to both muscle fiber development and function. Loss of some RyRs had modest effects, altering muscle fiber-type specification in the embryo without compromising viability. In addition, each RyR-encoding gene contributed to normal swimming behavior and muscle function. The RyR channels do not function in a simple additive manner. For example, although isoform RyR1a is sufficient for muscle contraction in the absence of RyR1b, RyR1a normally attenuates the activity of the co-expressed RyR1b channel in slow muscle. RyR3 also acts to modify the functions of other RyR channels. Furthermore, diminished RyR-dependent contractility affects both muscle fiber maturation and craniofacial development. These findings help to explain some of the heterogeneity of phenotypes that accompany RyR1 mutations in humans.
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Affiliation(s)
- Alexis A Chagovetz
- Department of Human Genetics, University of Utah, Salt Lake City, UT 84112, USA
| | - Dana Klatt Shaw
- Department of Human Genetics, University of Utah, Salt Lake City, UT 84112, USA
| | - Erin Ritchie
- Department of Human Genetics, University of Utah, Salt Lake City, UT 84112, USA
| | - Kazuyuki Hoshijima
- Department of Human Genetics, University of Utah, Salt Lake City, UT 84112, USA
| | - David J Grunwald
- Department of Human Genetics, University of Utah, Salt Lake City, UT 84112, USA
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25
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Abstract
PURPOSE OF REVIEW We will give an overview of neuromuscular disorders that can be linked with malignant hyperthermia or malignant hyperthermia-like reactions, and suggest an appropriate approach to interpret the risks. RECENT FINDINGS An increasing number of neuromuscular phenotypes have been linked to malignant hyperthermia susceptibility (MHS). This is for an important part due to the highly variable phenotype associated with mutations in the ryanodine receptor 1 gene (RYR1), the gene most frequently associated with MHS. A RYR1-mutation or a clinical RYR1-phenotype does not automatically translate in MHS, but precautions should be taken nonetheless. In addition, several other genes and phenotypes are now considered to be associated with MHS. In contrast, several neuromuscular diseases that were long thought to be linked to MHS are now known to cause malignant hyperthermia-like reactions instead of malignant hyperthermia. This is highly relevant as not only the given preoperative advice differs, but also acute treatment. SUMMARY This review provides a summary of current evidence linking certain neuromuscular diseases to malignant hyperthermia or malignant hyperthermia-like reactions. We provide a guide for the clinician, to determine which patients are at risk of malignant hyperthermia or malignant hyperthermia-like reactions perioperatively, and to ensure adequate treatment in case such a severe acute complication occurs.
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26
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RYR1 Sequence Variants in Myopathies: Expression and Functional Studies in Two Families. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7638946. [PMID: 31165076 PMCID: PMC6500691 DOI: 10.1155/2019/7638946] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/19/2019] [Indexed: 12/26/2022]
Abstract
The skeletal muscle ryanodine receptor (RyR1), i.e., the Ca2+ channel of the sarco/endoplasmic reticulum (S/ER), and the voltage-dependent calcium channel Cav1.1 are the principal channels involved in excitation-contraction coupling in skeletal muscle. RYR1 gene variants are linked to distinct skeletal muscle disorders, including malignant hyperthermia susceptibility and central core disease (CCD), mainly with autosomal dominant inheritance, and autosomal recessive myopathies with a broad phenotypic and histopathological spectrum. The age at onset of RYR1-related myopathies varies from infancy to adulthood. We report the identification of four RYR1 variants in two Italian families: one with myopathy and variants c.4003C>T (p.R1335C) and c.7035C>A (p.S2345R), and another with CCD and variants c.9293G>T (p.S3098I) and c.14771_14772insTAGACAGGGTGTTGCTCTGTTGCCCTTCTT (p.F4924_V4925insRQGVALLPFF). We demonstrate that, in patient-specific lymphoblastoid cells, the c.4003C>T (p.R1335C) variant is not expressed and the in-frame 30-nucleotide insertion variant is expressed at a low level. Moreover, Ca2+ release in response to the RyR1 agonist 4-chloro-m-cresol and to thapsigargin showed that the c.7035C>A (p.S2345R) variant causes depletion of S/ER Ca2+ stores and that the compound heterozygosity for variant c.9293G>T (p.S3098I) and the 30-nucleotide insertion increases RyR1-dependent Ca2+ release without affecting ER Ca2+ stores. In conclusion, we detected and functionally characterized disease-causing variants of the RyR1 channel in patient-specific lymphoblastoid cells. This paper is dedicated to the memory and contribution of Luigi Del Vecchio.
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27
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Abstract
The congenital myopathies are a genetically heterogeneous and diverse group of early-onset, nondystrophic neuromuscular disorders. While the originally reported "classical" entities within this group - Central Core Disease, Multiminicore Disease, Nemaline Myopathy, and Centronuclear Myopathy - were defined by the predominant finding on muscle biopsy, "novel" forms with multiple, subtle, and unusual histopathologic features have been described more recently, reflective of an expanding phenotypical spectrum. The main disease mechanisms concern excitation-contraction coupling, intracellular calcium homeostasis, and thin/thick filament interactions. Management to date has been mainly supportive. Therapeutic strategies currently at various stages of exploration include genetic interventions aimed at direct correction of the underlying genetic defect, enzyme replacement therapy, and pharmacologic approaches, either specifically targeting the principal effect of the underlying gene mutation, or addressing its downstream consequences more generally. Clinical trial development is accelerating but will require more robust natural history data and tailored outcome measures.
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Affiliation(s)
- Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, United Kingdom; Randall Division for Cell and Molecular Biophysics, Muscle Signalling Section, London, United Kingdom; Department of Basic and Clinical Neuroscience, IoPPN, King's College, London, United Kingdom.
| | - Francesco Muntoni
- The Dubowitz Neuromuscular Centre, Developmental Neurosciences Programme, UCL Great Ormond Street Institute of Child Health & Great Ormond Street Hospital for Children, London, United Kingdom; NIHR Great Ormond Street Hospital Biomedical Research Centre, London, United Kingdom
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28
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Gonorazky HD, Dowling JJ, Volpatti JR, Vajsar J. Signs and Symptoms in Congenital Myopathies. Semin Pediatr Neurol 2019; 29:3-11. [PMID: 31060723 DOI: 10.1016/j.spen.2019.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Congenital myopathies (CM) represent a continuously growing group of disorders with a wide range of clinical and histopathologic presentations. The refinement and application of new technologies for genetic diagnosis have broadened our understanding of the genetic causes of CM. Our growing knowledge has revealed that there are no clear limits between each subgroup of CM, and thus the clinical overlap between genes has become more evident. The implementation of next generation sequencing has produced vast amounts of genomic data that may be difficult to interpret. With an increasing number of reports revealing variants of unknown significance, it is essential to support the genetic diagnosis with a well characterized clinical description of the patient. Phenotype-genotype correlation should be a priority at the moment of disclosing the genetic results. Thus, a detailed physical examination can provide us with subtle differences that are not only key in order to arrive at a correct diagnosis, but also in the characterization of new myopathies and candidate genes.
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Affiliation(s)
- Hernan D Gonorazky
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James J Dowling
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Molecular Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonathan R Volpatti
- Department of Molecular Genetics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jiri Vajsar
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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29
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Knuiman GJ, Küsters B, Eshuis L, Snoeck M, Lammens M, Heytens L, De Ridder W, Baets J, Scalco RS, Quinlivan R, Holton J, Bodi I, Wraige E, Radunovic A, von Landenberg C, Reimann J, Kamsteeg EJ, Sewry C, Jungbluth H, Voermans NC. The histopathological spectrum of malignant hyperthermia and rhabdomyolysis due to RYR1 mutations. J Neurol 2019; 266:876-887. [PMID: 30788618 PMCID: PMC6420893 DOI: 10.1007/s00415-019-09209-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/16/2019] [Accepted: 01/19/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The histopathological features of malignant hyperthermia (MH) and non-anaesthetic (mostly exertional) rhabdomyolysis (RM) due to RYR1 mutations have only been reported in a few cases. METHODS We performed a retrospective multi-centre cohort study focussing on the histopathological features of patients with MH or RM due to RYR1 mutations (1987-2017). All muscle biopsies were reviewed by a neuromuscular pathologist. Additional morphometric and electron microscopic analysis were performed where possible. RESULTS Through the six participating centres we identified 50 patients from 46 families, including patients with MH (n = 31) and RM (n = 19). Overall, the biopsy of 90% of patients showed one or more myopathic features including: increased fibre size variability (n = 44), increase in the number of fibres with internal nuclei (n = 30), and type I fibre predominance (n = 13). Abnormalities on oxidative staining, generally considered to be more specifically associated with RYR1-related congenital myopathies, were observed in 52%, and included unevenness (n = 24), central cores (n = 7) and multi-minicores (n = 3). Apart from oxidative staining abnormalities more frequently observed in MH patients, the histopathological spectrum was similar between the two groups. There was no correlation between the presence of cores and the occurrence of clinically detectable weakness or presence of (likely) pathogenic variants. CONCLUSIONS Patients with RYR1-related MH and RM exhibit a similar histopathological spectrum, ranging from mild myopathic changes to cores and other features typical of RYR1-related congenital myopathies. Suggestive histopathological features may support RYR1 involvement, also in cases where the in vitro contracture test is not informative.
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Affiliation(s)
- G J Knuiman
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - B Küsters
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - L Eshuis
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M Snoeck
- National MH Investigation Unit, Department of Anaesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - M Lammens
- Department of Pathology, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - L Heytens
- Malignant Hyperthermia Research Unit, University of Antwerp, Antwerp, Belgium
| | - W De Ridder
- Neurogenetics Group, Center for Molecular Neurology, VIB, Antwerp, Belgium
- Laboratory of Neuromuscular Pathology, Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
- Department of Neurology, Neuromuscular Reference Centre, Antwerp University Hospital, Antwerp, Belgium
| | - J Baets
- Neurogenetics Group, Center for Molecular Neurology, VIB, Antwerp, Belgium
- Laboratory of Neuromuscular Pathology, Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
- Department of Neurology, Neuromuscular Reference Centre, Antwerp University Hospital, Antwerp, Belgium
| | - R S Scalco
- MRC Centre for Neuromuscular Diseases, Institute of Neurology, University College London, London, UK
| | - R Quinlivan
- MRC Centre for Neuromuscular Diseases, Institute of Neurology, University College London, London, UK
| | - J Holton
- MRC Centre for Neuromuscular Diseases, Institute of Neurology, University College London, London, UK
| | - I Bodi
- Department of Paediatric Neurology, Neuromuscular Service, Evelina Children's Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - E Wraige
- Department of Paediatric Neurology, Neuromuscular Service, Evelina Children's Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - A Radunovic
- Barts Neuromuscular Diseases Centre, Royal London Hospital, London, UK
| | - C von Landenberg
- Muscle Lab, Department of Neurology, University of Bonn Medical Centre, Bonn, Germany
| | - J Reimann
- Muscle Lab, Department of Neurology, University of Bonn Medical Centre, Bonn, Germany
| | - E-J Kamsteeg
- Department of Human Genetics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C Sewry
- Dubowitz Neuromuscular Centre, UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - H Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina Children's Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
- Muscle Signalling Section, Randall Division for Cell and Molecular Biophysics, King's College, London, UK
- Department of Basic and Clinical Neuroscience, King's College, IoPPN, London, UK
| | - N C Voermans
- Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands.
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30
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Hudig K, Pollock N, Bulger T, Machon RG, Woodhead A, Schiemann AH, Stowell KM. Masseter muscle rigidity and the role of DNA analysis to confirm malignant hyperthermia susceptibility. Anaesth Intensive Care 2019; 47:60-68. [PMID: 30864471 DOI: 10.1177/0310057x18811816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Malignant hyperthermia (MH) is an uncommon, autosomal dominant disorder of skeletal muscle, triggered by inhalational anaesthetics or depolarizing muscle relaxants. Masseter muscle rigidity (MMR) can be regarded as potentially a preceding sign for an MH reaction. Susceptibility to MH can be determined by the in vitro contracture test (IVCT) or DNA analysis where a familial variant is known. Our aims were to review patients with MMR, where IVCT and DNA analysis had been undertaken, to determine if DNA analysis could be used as an initial screening tool for MH susceptibility, and, by reviewing standard monitored variables (SMVs), to determine if any clinical characteristics could be used to differentiate between MMR patients who are MH susceptible (MHS) and those who are not. Patients with MMR were identified from the Palmerston North Hospital MH Reactions Database. IVCT and DNA analysis results were documented. DNA testing was performed retrospectively in the majority of patients as many patients had presented before DNA analysis was available. Forty-one patients were analysed. Fourteen were DNA positive/IVCT positive and six DNA positive only (48% in total), seven were IVCT positive/DNA negative and 14 were IVCT normal. Increased creatine kinase (>18,000 units/L) was consistent with MH susceptibility. Severity of MMR was not linked to MH susceptibility. This study confirmed that DNA analysis can be used as a first-line test for MH susceptibility in patients presenting with MMR (consistent with European MH Group recommendations). Creatine kinase was the only SMV that was significantly different between MHS and MH normal individuals.
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Affiliation(s)
- Kate Hudig
- 1 Department of Anaesthesia, Starship Children's Hospital, New Zealand
| | - Neil Pollock
- 2 Department of Anaesthesia and Intensive Care, Palmerston North Hospital, New Zealand
| | - Terasa Bulger
- 2 Department of Anaesthesia and Intensive Care, Palmerston North Hospital, New Zealand
| | - Roslyn G Machon
- 2 Department of Anaesthesia and Intensive Care, Palmerston North Hospital, New Zealand
| | - Andrew Woodhead
- 3 Department of Anaesthesia and Pain Management, Wellington Regional Hospital, New Zealand
| | - Anja H Schiemann
- 4 Institute of Fundamental Sciences, Massey University, New Zealand
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31
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Jokela M, Tasca G, Vihola A, Mercuri E, Jonson PH, Lehtinen S, Välipakka S, Pane M, Donati M, Johari M, Savarese M, Huovinen S, Isohanni P, Palmio J, Hartikainen P, Udd B. An unusual ryanodine receptor 1 (RYR1) phenotype: Mild calf-predominant myopathy. Neurology 2019; 92:e1600-e1609. [PMID: 30842289 DOI: 10.1212/wnl.0000000000007246] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/03/2018] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To identify the genetic defect causing a distal calf myopathy with cores. METHODS Families with a genetically undetermined calf-predominant myopathy underwent detailed clinical evaluation, including EMG/nerve conduction studies, muscle biopsy, laboratory investigations, and muscle MRI. Next-generation sequencing and targeted Sanger sequencing were used to identify the causative genetic defect in each family. RESULTS A novel deletion-insertion mutation in ryanodine receptor 1 (RYR1) was found in the proband of the index family and segregated with the disease in 6 affected relatives. Subsequently, we found 2 more families with a similar calf-predominant myopathy segregating with unique RYR1-mutated alleles. All patients showed a very slowly progressive myopathy without episodes of malignant hyperthermia or rhabdomyolysis. Muscle biopsy showed cores or core-like changes in all families. CONCLUSIONS Our findings expand the spectrum of RYR1-related disorders to include a calf-predominant myopathy with core pathology and autosomal dominant inheritance. Two families had unique and previously unreported RYR1 mutations, while affected persons in the third family carried 2 previously known mutations in the same dominant allele.
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Affiliation(s)
- Manu Jokela
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland.
| | - Giorgio Tasca
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Anna Vihola
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Eugenio Mercuri
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Per-Harald Jonson
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Sara Lehtinen
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Salla Välipakka
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Marika Pane
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Maria Donati
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Mridul Johari
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Marco Savarese
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Sanna Huovinen
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Pirjo Isohanni
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Johanna Palmio
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Päivi Hartikainen
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
| | - Bjarne Udd
- From the Neuromuscular Research Center (M. Jokela, S.L., J.P., B.U.), Department of Neurology, University Hospital and University of Tampere; Division of Clinical Neurosciences (M. Jokela), Department of Neurology, Turku University Hospital and University of Turku; Kiinamyllynkatu 4-8 (M. Jokela), Turku, Finland; Unità Operativa Complessa di Neurologia (G.T.), Dipartimento di Scienze dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Folkhälsan Institute of Genetics and Department of Medical Genetics (A.V., P.-H.J., S.V., M. Johari, M.S.), Haartman Institute, University of Helsinki, Finland; Institute of Pediatric Neurology (E.M., M.P.), Catholic University School of Medicine, Rome, Italy; Department of Pathology (S.H.), Fimlab Laboratories, Tampere University Hospital, Finland; Metabolic and Neuromuscular Unit (M.D.), Meyer Hospital, Florence, Italy; Department of Pediatric Neurology (P.I.), Children's Hospital, University of Helsinki and Helsinki University Hospital; Department of Neurology (P.H.), Kuopio University Hospital and University of Eastern Finland; and Department of Neurology (B.U.), Vasa Central Hospital, Finland
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32
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Gonsalves SG, Dirksen RT, Sangkuhl K, Pulk R, Alvarellos M, Vo T, Hikino K, Roden D, Klein TE, Poler SM, Patel S, Caudle KE, Gordon R, Brandom B, Biesecker LG. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for the Use of Potent Volatile Anesthetic Agents and Succinylcholine in the Context of RYR1 or CACNA1S Genotypes. Clin Pharmacol Ther 2019; 105:1338-1344. [PMID: 30499100 DOI: 10.1002/cpt.1319] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 11/20/2018] [Indexed: 11/09/2022]
Abstract
The identification in a patient of 1 of the 50 variants in the RYR1 or CACNA1S genes reviewed here should lead to a presumption of malignant hyperthermia susceptibility (MHS). MHS can lead to life-threatening reactions to potent volatile anesthetic agents or succinylcholine. We summarize evidence from the literature supporting this association and provide therapeutic recommendations for the use of these agents in patients with these RYR1 or CACNA1S variants (updates at https://cpicpgx.org/guidelines and www.pharmgkb.org).
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Affiliation(s)
- Stephen G Gonsalves
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Robert T Dirksen
- Department of Pharmacology & Physiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Rebecca Pulk
- Center for Pharmacy Innovation and Outcomes, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Maria Alvarellos
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - Teresa Vo
- Department of Pharmacy Practice, College of Medicine Internal Medicine, College of Pharmacy, University of South Florida, Tampa, Florida, USA
| | - Keiko Hikino
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, Illinois, USA
| | - Dan Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, California, USA
| | - S Mark Poler
- Departments of Anesthesiology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Sephalie Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Kelly E Caudle
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ronald Gordon
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Barbara Brandom
- Department of Anesthesiology, Mercy Hospital UPMC, North American MH Registry of MHAUS, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Leslie G Biesecker
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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33
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Todd JJ, Sagar V, Lawal TA, Allen C, Razaqyar MS, Shelton MS, Chrismer IC, Zhang X, Cosgrove MM, Kuo A, Vasavada R, Jain MS, Waite M, Rajapakse D, Witherspoon JW, Wistow G, Meilleur KG. Correlation of phenotype with genotype and protein structure in RYR1-related disorders. J Neurol 2018; 265:2506-2524. [PMID: 30155738 PMCID: PMC6182665 DOI: 10.1007/s00415-018-9033-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 08/17/2018] [Accepted: 08/18/2018] [Indexed: 01/01/2023]
Abstract
Variants in the skeletal muscle ryanodine receptor 1 gene (RYR1) result in a spectrum of RYR1-related disorders. Presentation during infancy is typical and ranges from delayed motor milestones and proximal muscle weakness to severe respiratory impairment and ophthalmoplegia. We aimed to elucidate correlations between genotype, protein structure and clinical phenotype in this rare disease population. Genetic and clinical data from 47 affected individuals were analyzed and variants mapped to the cryo-EM RyR1 structure. Comparisons of clinical severity, motor and respiratory function and symptomatology were made according to the mode of inheritance and affected RyR1 structural domain(s). Overall, 49 RYR1 variants were identified in 47 cases (dominant/de novo, n = 35; recessive, n = 12). Three variants were previously unreported. In recessive cases, facial weakness, neonatal hypotonia, ophthalmoplegia/paresis, ptosis, and scapular winging were more frequently observed than in dominant/de novo cases (all, p < 0.05). Both dominant/de novo and recessive cases exhibited core myopathy histopathology. Clinically severe cases were typically recessive or had variants localized to the RyR1 cytosolic shell domain. Motor deficits were most apparent in the MFM-32 standing and transfers dimension, [median (IQR) 85.4 (18.8)% of maximum score] and recessive cases exhibited significantly greater overall motor function impairment compared to dominant/de novo cases [79.7 (18.8)% vs. 87.5 (17.7)% of maximum score, p = 0.03]. Variant mapping revealed patterns of clinical severity across RyR1 domains, including a structural plane of interest within the RyR1 cytosolic shell, in which 84% of variants affected the bridging solenoid. We have corroborated genotype-phenotype correlations and identified RyR1 regions that may be especially sensitive to structural modification.
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Affiliation(s)
- Joshua J Todd
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA.
| | - Vatsala Sagar
- Section on Molecular Structure and Functional Genomics, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tokunbor A Lawal
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
| | - Carolyn Allen
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
| | - Muslima S Razaqyar
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
| | - Monique S Shelton
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
| | - Irene C Chrismer
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
| | - Xuemin Zhang
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
| | - Mary M Cosgrove
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
| | - Anna Kuo
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
| | - Ruhi Vasavada
- Mark O. Hatfield Clinical Research Center, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD, USA
| | - Minal S Jain
- Mark O. Hatfield Clinical Research Center, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD, USA
| | - Melissa Waite
- Mark O. Hatfield Clinical Research Center, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD, USA
| | - Dinusha Rajapakse
- Section on Molecular Structure and Functional Genomics, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jessica W Witherspoon
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
| | - Graeme Wistow
- Section on Molecular Structure and Functional Genomics, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Katherine G Meilleur
- Neuromuscular Symptoms Unit, Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, 10 Center Drive, Room 2A07, Bethesda, MD, 20892, USA
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Abstract
Ryanodine receptor type 1-related myopathies (RYR1-RM) are the most common class of congenital myopathies. Historically, RYR1-RM classification and diagnosis have been guided by histopathologic findings on muscle biopsy. Main histological subtypes of RYR1-RM include central core disease, multiminicore disease, core-rod myopathy, centronuclear myopathy, and congenital fiber-type disproportion. A range of RYR1-RM clinical phenotypes has also emerged more recently and includes King Denborough syndrome, RYR1 rhabdomyolysis-myalgia syndrome, atypical periodic paralysis, congenital neuromuscular disease with uniform type 1 fibers, and late-onset axial myopathy. This expansion of the RYR1-RM disease spectrum is due, in part, to implementation of next-generation sequencing methods, which include the entire RYR1 coding sequence rather than being restricted to hotspot regions. These methods enhance diagnostic capabilities, especially given historic limitations of histopathologic and clinical overlap across RYR1-RM. Both dominant and recessive modes of inheritance have been documented, with the latter typically associated with a more severe clinical phenotype. As with all congenital myopathies, no FDA-approved treatments exist to date. Here, we review histopathologic, clinical, imaging, and genetic diagnostic features of the main RYR1-RM subtypes. We also discuss the current state of treatments and focus on disease-modulating (nongenetic) therapeutic strategies under development for RYR1-RM. Finally, perspectives for future approaches to treatment development are broached.
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Affiliation(s)
- Tokunbor A Lawal
- Neuromuscular Symptoms Unit, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Joshua J Todd
- Neuromuscular Symptoms Unit, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA
| | - Katherine G Meilleur
- Neuromuscular Symptoms Unit, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, USA.
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35
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Sewry CA, Wallgren-Pettersson C. Myopathology in congenital myopathies. Neuropathol Appl Neurobiol 2018; 43:5-23. [PMID: 27976420 DOI: 10.1111/nan.12369] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 12/03/2016] [Indexed: 12/18/2022]
Abstract
Congenital myopathies are clinically and genetically a heterogeneous group of early onset neuromuscular disorders, characterized by hypotonia and muscle weakness. Clinical severity and age of onset are variable. Many patients are severely affected at birth while others have a milder, moderately progressive or nonprogressive phenotype. Respiratory weakness is a major clinical aspect that requires regular monitoring. Causative mutations in several genes have been identified that are inherited in a dominant, recessive or X-linked manner, or arise de novo. Muscle biopsies show characteristic pathological features such as nemaline rods/bodies, cores, central nuclei or caps. Small type 1 fibres expressing slow myosin are a common feature and may sometimes be the only abnormality. Small cores (minicores) devoid of mitochondria and areas showing variable myofibrillar disruption occur in several neuromuscular disorders including several forms of congenital myopathy. Muscle biopsies can also show more than one structural defect. There is considerable clinical, pathological and genetic overlap with mutations in one gene resulting in more than one pathological feature, and the same pathological feature being associated with defects in more than one gene. Increasing application of whole exome sequencing is broadening the clinical and pathological spectra in congenital myopathies, but pathology still has a role in clarifying the pathogenicity of gene variants as well as directing molecular analysis.
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Affiliation(s)
- C A Sewry
- Dubowitz Neuromuscular Centre, UCL Institute of Child Health and Great Ormond Street Hospital for Children, London, UK.,Wolfson Centre for Inherited Neuromuscular Diseases, RJAH Orthopaedic Hospital, Oswestry, UK
| | - C Wallgren-Pettersson
- The Folkhälsan Institute of Genetics and the Department of Medical and Clinical Genetics, University of Helsinki, Helsinki, Finland
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36
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Congenital myopathies: disorders of excitation-contraction coupling and muscle contraction. Nat Rev Neurol 2018; 14:151-167. [PMID: 29391587 DOI: 10.1038/nrneurol.2017.191] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The congenital myopathies are a group of early-onset, non-dystrophic neuromuscular conditions with characteristic muscle biopsy findings, variable severity and a stable or slowly progressive course. Pronounced weakness in axial and proximal muscle groups is a common feature, and involvement of extraocular, cardiorespiratory and/or distal muscles can implicate specific genetic defects. Central core disease (CCD), multi-minicore disease (MmD), centronuclear myopathy (CNM) and nemaline myopathy were among the first congenital myopathies to be reported, and they still represent the main diagnostic categories. However, these entities seem to belong to a much wider phenotypic spectrum. To date, congenital myopathies have been attributed to mutations in over 20 genes, which encode proteins implicated in skeletal muscle Ca2+ homeostasis, excitation-contraction coupling, thin-thick filament assembly and interactions, and other mechanisms. RYR1 mutations are the most frequent genetic cause, and CCD and MmD are the most common subgroups. Next-generation sequencing has vastly improved mutation detection and has enabled the identification of novel genetic backgrounds. At present, management of congenital myopathies is largely supportive, although new therapeutic approaches are reaching the clinical trial stage.
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37
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Abstract
PURPOSE OF REVIEW This article reviews adult presentations of the major congenital myopathies - central core disease, multiminicore disease, centronuclear myopathy and nemaline myopathy - with an emphasis on common genetic backgrounds, typical clinicopathological features and differential diagnosis. RECENT FINDINGS The congenital myopathies are a genetically heterogeneous group of conditions with characteristic histopathological features. Although essentially considered paediatric conditions, some forms - in particular those due to dominant mutations in the skeletal muscle ryanodine receptor (RYR1), the dynamin 2 (DNM2), the amphiphysin 2 (BIN1) and the Kelch repeat-and BTB/POZ domain-containing protein 13 (KBTBD13) gene - may present late into adulthood. Moreover, dominant RYR1 mutations associated with the malignant hyperthermia susceptibility trait have been recently identified as a common cause of (exertional) rhabdomyolysis presenting throughout life. In addition, improved standards of care and development of new therapies will result in an increasing number of patients with early-onset presentations transitioning to the adult neuromuscular clinic. Lastly, if nemaline rods are the predominant histopathological feature, acquired treatable conditions have to be considered in the differential diagnosis. SUMMARY Recently identified genotypes and phenotypes indicate a spectrum of the congenital myopathies extending into late adulthood, with important implications for clinical practice.
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Abstract
This review identifies disease states associated with malignant hyperthermia susceptibility based on genotypic and phenotypic findings, and a framework is established for clinicians to identify a potentially malignant hyperthermia–susceptible patient.
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39
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Abstract
This article reviews advancements in the genetics of malignant hyperthermia, new technologies and approaches for its diagnosis, and the existing limitations of genetic testing for malignant hyperthermia. It also reviews the various RYR1-related disorders and phenotypes, such as myopathies, exertional rhabdomyolysis, and bleeding disorders, and examines the connection between these disorders and malignant hyperthermia.
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Evidence of Malignant Hyperthermia in Patients Administered Triggering Agents before Malignant Hyperthermia Susceptibility Identified: Missed Opportunities Prior to Diagnosis. Anaesth Intensive Care 2017; 45:707-713. [DOI: 10.1177/0310057x1704500610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Malignant hyperthermia (MH) is a hypermetabolic disorder of skeletal muscle triggered almost exclusively by potent inhalational agents and suxamethonium. Signs of an MH reaction are non-specific and may be confused with the presentation of other problems such as sepsis and overheating of a patient. A high index of suspicion is needed to be aware of an early presentation of MH. Nine patients are presented who showed abnormal signs with an earlier anaesthetic where the possible diagnosis of an MH reaction was missed. These patients either presented later with an MH reaction, confirmed by DNA analysis and in some cases in vitro contracture testing, or were diagnosed by the identification of a causative mutation confirming MH susceptibility. The MH clinical grading scale is helpful in determining the likelihood that clinical indicators indicate a possible MH reaction. Masseter muscle rigidity is a known sign of MH, confirmed in this report by positive in vitro contracture testing and DNA analysis. Several uncommon muscle disorders have a high association with MH, and postoperative myalgia unrelated to suxamethonium can be a sign which is associated with MH. These reports emphasise the importance of a thorough family history (as the MH status was known by the family in four patients), a high index of suspicion for MH, and documentation of the possibility of MH susceptibility in the anaesthesia record.
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Brackmann F, Türk M, Gratzki N, Rompel O, Jungbluth H, Schröder R, Trollmann R. Compound heterozygous RYR1 mutations in a preterm with arthrogryposis multiplex congenita and prenatal CNS bleeding. Neuromuscul Disord 2017; 28:54-58. [PMID: 29169929 DOI: 10.1016/j.nmd.2017.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 08/28/2017] [Accepted: 09/18/2017] [Indexed: 01/23/2023]
Abstract
RYR1 mutations, the most common cause of non-dystrophic neuromuscular disorders, are associated with the malignant hyperthermia susceptibility (MHS) trait as well as congenital myopathies with widely variable clinical and histopathological manifestations. Recently, bleeding anomalies have been reported in association with certain RYR1 mutations. Here we report a preterm infant born at 32 weeks gestation with arthrogryposis multiplex congenita due to compound heterozygous, previously MHS-associated RYR1 mutations, with additional signs of prenatal hemorrhage. The patient presented at birth with multiple joint contractures, scoliosis, severe thoracic rigidity and respiratory failure. He continued to depend on mechanical ventilation and tube feeding. Muscle histopathology showed a marked myopathic pattern with eccentric cores. Interestingly, the patient had additional unusual prenatal intraventricular hemorrhage, resulting in post-hemorrhagic hydrocephalus as well as epidural hemorrhage affecting the spinal cord. This report adds to the phenotypic variability associated with RYR1 mutations, and highlights possible bleeding complications in affected individuals.
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Affiliation(s)
- Florian Brackmann
- Department of Pediatrics, Neuropediatrics, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Federal Republic of Germany.
| | - Matthias Türk
- Department of Neurology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Federal Republic of Germany
| | - Nils Gratzki
- Department of Pediatrics, Neonatology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Federal Republic of Germany
| | - Oliver Rompel
- Department of Radiology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Federal Republic of Germany
| | - Heinz Jungbluth
- Department of Pediatric Neurology, Neuromuscular Service, Evelina Children's Hospital, St Thomas' Hospital, London, UK; Randall Division of Cell and Molecular, Biophysics Muscle Signalling Section, King's College, London, UK; Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College, London, UK
| | - Rolf Schröder
- Department of Neuropathology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Federal Republic of Germany
| | - Regina Trollmann
- Department of Pediatrics, Neuropediatrics, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Federal Republic of Germany
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42
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Levano S, Gonzalez A, Singer M, Demougin P, Rüffert H, Urwyler A, Girard T. Resequencing array for gene variant detection in malignant hyperthermia and butyrylcholinestherase deficiency. Neuromuscul Disord 2017; 27:492-499. [PMID: 28259615 DOI: 10.1016/j.nmd.2017.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 12/20/2016] [Accepted: 02/15/2017] [Indexed: 11/30/2022]
Abstract
Malignant hyperthermia (MH) and butyrylcholinestherase (BCHE) deficiency are two relevant pharmacogenetic disorders in anesthetic practice linked with sequence variants, the former in the RyR1 and CACNA1S genes, the latter in the BCHE gene. Genotyping for known pathogenic variants in these genes is useful to help identify susceptible individuals, and others may exist but remain unknown, because full-length sequence of these genes is, in general, not investigated. To facilitate this task, we developed a resequencing DNA array, the perioperative patient safety (POPS) array, to be able to screen the entire coding sequences of the RyR1, CACNA1S and BCHE genes. MH-susceptible individuals (n = 121) identified with the in vitro contracture test, the standard diagnostic tool for MH susceptibility, were genotyped with the arrays. Compared with capillary sequencing, call rates with the arrays could achieve 100% at maximal sensitivity, although to reduce false positive rates, sensitivity was adjusted to 0.85, 0.87 and 0.66 for RyR1, CACNA1S and BCHE respectively, with overall base call specificity exceeding 99%. Detection of 29 predetermined RyR1 variants in 44 individuals was successful in 97% of the cases, among them all 16 variants of established diagnostic value. In a trial application of the arrays, 21 MH-susceptible subjects with no known RyR1 or CACNA1S variants were screened, resulting in the discovery of new variants, all confirmed by capillary sequencing. In conclusion, arrays offer an efficient high-throughput alternative for diagnostic genotyping of candidate genes affecting MH susceptibility, BCHE deficiency and other neuromuscular disorders, simultaneously enabling a comprehensive search for rare variants in these genes.
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Affiliation(s)
- Soledad Levano
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland
| | - Asensio Gonzalez
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland.
| | - Martine Singer
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland
| | - Philippe Demougin
- Biozentrum, Life Sciences Training Facility, University of Basel, Switzerland
| | - Henrik Rüffert
- University of Leipzig, Helios Kliniken Leipziger Land Leipzig, Germany
| | - Albert Urwyler
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland
| | - Thierry Girard
- Department of Biomedicine, University Hospital Basel, Switzerland; Department Anesthesiology, University Hospital Basel, Switzerland
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43
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Joseph MR, Theroux MC, Mooney JJ, Falitz S, Brandom BW, Byler DL. Intraoperative Presentation of Malignant Hyperthermia (Confirmed by RYR1 Gene Mutation, c.7522C>T; p.R2508C) Leads to Diagnosis of King-Denborough Syndrome in a Child With Hypotonia and Dysmorphic Features. ACTA ACUST UNITED AC 2017; 8:55-57. [DOI: 10.1213/xaa.0000000000000421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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44
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Witherspoon JW, Meilleur KG. Review of RyR1 pathway and associated pathomechanisms. Acta Neuropathol Commun 2016; 4:121. [PMID: 27855725 PMCID: PMC5114830 DOI: 10.1186/s40478-016-0392-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/02/2016] [Indexed: 02/04/2023] Open
Abstract
Ryanodine receptor isoform-1 (RyR1) is a major calcium channel in skeletal muscle important for excitation-contraction coupling. Mutations in the RYR1 gene yield RyR1 protein dysfunction that manifests clinically as RYR1-related congenital myopathies (RYR1-RM) and/or malignant hyperthermia susceptibility (MHS). Individuals with RYR1-RM and/or MHS exhibit varying symptoms and severity. The symptoms impair quality of life and put patients at risk for early mortality, yet the cause of varying severity is not well understood. Currently, there is no Food and Drug Administration (FDA) approved treatment for RYR1-RM. Discovery of effective treatments is therefore critical, requiring knowledge of the RyR1 pathway. The purpose of this review is to compile work published to date on the RyR1 pathway and to implicate potential regions as targets for treatment. The RyR1 pathway is comprised of protein-protein interactions, protein-ligand interactions, and post-translational modifications, creating an activation/regulatory macromolecular complex. Given the complexity of this pathway, we divided these interactions and modifications into six regulatory groups. Three of several RyR1 interacting proteins, FK506-binding protein 12 (FKBP12), triadin, and calmodulin, were identified as playing important roles across all groups and may serve as promising target sites for treatment. Also, variability in disease severity may be influenced by prolongation or hyperactivity of post-translational modifications resulting from RyR1 dysfunction.
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Voermans NC, Snoeck M, Jungbluth H. RYR1-related rhabdomyolysis: A common but probably underdiagnosed manifestation of skeletal muscle ryanodine receptor dysfunction. Rev Neurol (Paris) 2016; 172:546-558. [PMID: 27663056 DOI: 10.1016/j.neurol.2016.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/29/2016] [Indexed: 01/04/2023]
Abstract
Mutations in the skeletal muscle ryanodine receptor (RYR1) gene are associated with a wide spectrum of inherited myopathies presenting throughout life. Malignant hyperthermia susceptibility (MHS)-related RYR1 mutations have emerged as a common cause of exertional rhabdomyolysis, accounting for up to 30% of rhabdomyolysis episodes in otherwise healthy individuals. Common triggers are exercise and heat and, less frequently, viral infections, alcohol and drugs. Most subjects are normally strong and have no personal or family history of malignant hyperthermia. Heat intolerance and cold-induced muscle stiffness may be a feature. Recognition of this (probably not uncommon) rhabdomyolysis cause is vital for effective counselling, to identify potentially malignant hyperthermia-susceptible individuals and to adapt training regimes. Studies in various animal models provide insights regarding possible pathophysiological mechanisms and offer therapeutic perspectives.
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Affiliation(s)
- N C Voermans
- Department of Neurology, Radboud University Medical Centre, R. Postlaan 4 (route 935), P.O. Box 9101, 6500 Nijmegen (935), The Netherlands.
| | - M Snoeck
- Department of Anaesthesia, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - H Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK; Randall Division of Cell and Molecular Biophysics, Muscle Signalling Section, London, UK; Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
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Jungbluth H, Dowling JJ, Ferreiro A, Muntoni F, Bönnemann C, Dirksen R, Faure J, Hamilton S, Hopkins P, Marks A, Marty I, Meilleur K, Riazi S, Sewry C, Treves S, Voermans N, Zorzato F. 217th ENMC International Workshop: RYR1-related myopathies, Naarden, The Netherlands, 29–31 January 2016. Neuromuscul Disord 2016; 26:624-33. [DOI: 10.1016/j.nmd.2016.06.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 06/02/2016] [Indexed: 12/22/2022]
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Treves S, Jungbluth H, Voermans N, Muntoni F, Zorzato F. Ca 2+ handling abnormalities in early-onset muscle diseases: Novel concepts and perspectives. Semin Cell Dev Biol 2016; 64:201-212. [PMID: 27427513 DOI: 10.1016/j.semcdb.2016.07.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 07/14/2016] [Indexed: 12/17/2022]
Abstract
The physiological process by which Ca2+ is released from the sarcoplasmic reticulum is called excitation-contraction coupling; it is initiated by an action potential which travels deep into the muscle fiber where it is sensed by the dihydropyridine receptor, a voltage sensing L-type Ca2+channel localized on the transverse tubules. Voltage-induced conformational changes in the dihydropyridine receptor activate the ryanodine receptor Ca2+ release channel of the sarcoplasmic reticulum. The released Ca2+ binds to troponin C, enabling contractile thick-thin filament interactions. The Ca2+ is subsequently transported back into the sarcoplasmic reticulum by specialized Ca2+ pumps (SERCA), preparing the muscle for a new cycle of contraction. Although other proteins are involved in excitation-contraction coupling, the mechanism described above emphasizes the unique role played by the two Ca2+ channels (the dihydropyridine receptor and the ryanodine receptor), the SERCA Ca2+ pumps and the exquisite spatial organization of the membrane compartments endowed with the proteins responsible for this mechanism to function rapidly and efficiently. Research over the past two decades has uncovered the fine details of excitation-contraction coupling under normal conditions while advances in genomics have helped to identify mutations in novel genes in patients with neuromuscular disorders. While it is now clear that many patients with congenital muscle diseases carry mutations in genes encoding proteins directly involved in Ca2+ homeostasis, it has become apparent that mutations are also present in genes encoding for proteins not thought to be directly involved in Ca2+ regulation. Ongoing research in the field now focuses on understanding the functional effect of individual mutations, as well as understanding the role of proteins not specifically located in the sarcoplasmic reticulum which nevertheless are involved in Ca2+ regulation or excitation-contraction coupling. The principal challenge for the future is the identification of drug targets that can be pharmacologically manipulated by small molecules, with the ultimate aim to improve muscle function and quality of life of patients with congenital muscle disorders. The aim of this review is to give an overview of the most recent findings concerning Ca2+ dysregulation and its impact on muscle function in patients with congenital muscle disorders due to mutations in proteins involved in excitation-contraction coupling and more broadly on Ca2+ homeostasis.
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Affiliation(s)
- Susan Treves
- Departments of Biomedicine and Anesthesia, Basel University Hospital, 4031 Basel, Switzerland; Department of Life Sciences, General Pathology Section, University of Ferrara, 44100 Ferrara, Italy.
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina Children's Hospital, St. Thomas' Hospital, London, United Kingdom; Randall Division for Cell and Molecular Biophysics, Muscle Signalling Section, King's College, London, United Kingdom; Department of Basic and Clinical Neuroscience, IoPPN, King's College, London, United Kingdom
| | - Nicol Voermans
- Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Francesco Muntoni
- Dubowitz Neuromuscular Centre, Institute of Child Health, University College London, United Kingdom
| | - Francesco Zorzato
- Departments of Biomedicine and Anesthesia, Basel University Hospital, 4031 Basel, Switzerland; Department of Life Sciences, General Pathology Section, University of Ferrara, 44100 Ferrara, Italy
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Shapiro F, Athiraman U, Clendenin DJ, Hoagland M, Sethna NF. Anesthetic management of 877 pediatric patients undergoing muscle biopsy for neuromuscular disorders: a 20-year review. Paediatr Anaesth 2016; 26:710-21. [PMID: 27111691 DOI: 10.1111/pan.12909] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND The objectives are to review the anesthetic management and anesthetic-related adverse events in patients undergoing muscle biopsy for a broad spectrum of neuromuscular disorders (NMD). AIM The study aims to assess the hypothesis that perceived awareness of potential anesthesia-induced hyperkalemia and MH in patients with NMD reduces the frequency of such events. METHODS A 20-year retrospective review of 877 consecutive patients undergoing muscle biopsy to establish diagnoses of NMD has been performed. Patients were categorized prebiopsy into six groups: M (myopathy and muscular dystrophy), MM (mitochondrial or metabolic myopathy), N (neurodegenerative, peripheral neuropathy or spinal muscular atrophy disorder), D (dermatomyositis), C (cardiomyopathy), or S (seizure disorder). Data were collected for demographics, anesthetic management, pre- and postoperative anesthesia-induced muscle injury, postbiopsy histopathologic diagnosis, and concordance comparisons between pre- and postbiopsy diagnoses. RESULTS There were 513 males (58.5%) and 364 females (41.5%) (1.4:1) with 137 individuals (15.6%) operated on under 1 year of age and two-thirds by 6 years of age. NMD diagnosis was reached in 409 (46.6%) while 468 (53.4%) had no specific pathology. No patients exhibited signs of anesthesia-induced muscle injury (malignant hyperthermia, rhabdomyolysis, cardiac arrest, or postoperative deterioration of weakness). MM was the largest group pre biopsy (367, 41.8%). Anesthetic agents were: nitrous oxide in 657 (74.9%); volatile agents in 139 (15.8%); intravenous agents in 836 (95.3%) (primarily propofol, midazolam, and fentanyl); nondepolarizing muscle relaxants in 404 (46.1%); and regional anesthesia in 112 (12.8%) [most commonly spinal anesthesia in 80 (71.4%)]. Comparing preoperative diagnostic category with postoperative diagnosis, there was a concordance of 78% (319/409) between the two for cases with a definitive diagnosis and 89.7% (787/877) for all cases. CONCLUSIONS In this retrospective study, no patient exhibited signs or symptoms of hyperkalemia or MH probably because the incidence is very low and becomes even less likely due to the selection of the various anesthetic agents and strategies administered.
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Affiliation(s)
- Frederic Shapiro
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Umeshkumar Athiraman
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - David J Clendenin
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Monica Hoagland
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Navil F Sethna
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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Cong X, Doering J, Mazala DAG, Chin ER, Grange RW, Jiang H. The SH3 and cysteine-rich domain 3 (Stac3) gene is important to growth, fiber composition, and calcium release from the sarcoplasmic reticulum in postnatal skeletal muscle. Skelet Muscle 2016; 6:17. [PMID: 27073615 PMCID: PMC4828897 DOI: 10.1186/s13395-016-0088-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/30/2016] [Indexed: 12/25/2022] Open
Abstract
Background The SH3 and cysteine-rich domain 3 (Stac3) gene is specifically expressed in the skeletal muscle. Stac3 knockout mice die perinatally. In this study, we determined the potential role of Stac3 in postnatal skeletal muscle growth, fiber composition, and contraction by generating conditional Stac3 knockout mice. Methods We disrupted the Stac3 gene in 4-week-old male mice using the Flp-FRT and tamoxifen-inducible Cre-loxP systems. Results RT-qPCR and western blotting analyses of the limb muscles of target mice indicated that nearly all Stac3 mRNA and more than 70 % of STAC3 protein were deleted 4 weeks after tamoxifen injection. Postnatal Stac3 deletion inhibited body and limb muscle mass gains. Histological staining and gene expression analyses revealed that postnatal Stac3 deletion decreased the size of myofibers and increased the percentage of myofibers containing centralized nuclei, with no effect on the total myofiber number. Grip strength and grip time tests indicated that postnatal Stac3 deletion decreased limb muscle strength in mice. Muscle contractile tests revealed that postnatal Stac3 deletion reduced electrostimulation-induced but not the ryanodine receptor agonist caffeine-induced maximal force output in the limb muscles. Calcium imaging analysis of single flexor digitorum brevis myofibers indicated that postnatal Stac3 deletion reduced electrostimulation- but not caffeine-induced calcium release from the sarcoplasmic reticulum. Conclusions This study demonstrates that STAC3 is important to myofiber hypertrophy, myofiber-type composition, contraction, and excitation-induced calcium release from the sarcoplasmic reticulum in the postnatal skeletal muscle. Electronic supplementary material The online version of this article (doi:10.1186/s13395-016-0088-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiaofei Cong
- Department of Animal and Poultry Sciences, Virginia Tech, Blacksburg, VA USA
| | - Jonathan Doering
- Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, VA USA
| | - Davi A G Mazala
- Department of Kinesiology, School of Public Health, University of Maryland, College Park, MD USA
| | - Eva R Chin
- Department of Kinesiology, School of Public Health, University of Maryland, College Park, MD USA
| | - Robert W Grange
- Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, VA USA
| | - Honglin Jiang
- Department of Animal and Poultry Sciences, Virginia Tech, Blacksburg, VA USA
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Zhao Y, Hu J, Zhao Z, Shen H, Bing Q, Li N. Next generation sequencing reveals ryanodine receptor 1 mutations in a Chinese central core disease cohort. Muscle Nerve 2016; 54:432-8. [PMID: 26799446 DOI: 10.1002/mus.25050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Revised: 12/02/2015] [Accepted: 01/14/2016] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Ryanodine receptor 1 (RYR1), myosin heavy chain 7 (MYH7), and selenoprotein N1 (SEPN1) mutations are associated with core myopathies. RYR1 mutations cause most cases of central core disease (CCD). METHODS We screened 8 Chinese patients with clinicopathological diagnosis of CCD. Genetic analysis was carried out by targeted next generation sequencing (NGS) to identify causative genes. Variants were assessed for pathogenicity using bioinformatic approaches, and NGS results were confirmed by Sanger sequencing. RESULTS One novel (p.L4578V) and heterozygous missense mutations in RYR1 were identified in 7 patients. Two patients carried a novel mutation, 1 had p.M4640R, 3 had p.R4861H, and 1 had p.R4861C. All patients had mild to moderate severity phenotypes. Histopathological findings demonstrated central cores and type I fiber predominance. CONCLUSIONS NGS is an efficient strategy to identify variants in RYR1 in CCD. However, genetic results revealed by NGS must be combined with clinicopathologic features to validate the diagnosis. Muscle Nerve, 2016 Muscle Nerve 54: 432-438, 2016.
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Affiliation(s)
- Yan Zhao
- Department of Neuromuscular Disease, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang City, Hebei Province, 050051, PR China
| | - Jing Hu
- Department of Neuromuscular Disease, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang City, Hebei Province, 050051, PR China
| | - Zhe Zhao
- Department of Neuromuscular Disease, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang City, Hebei Province, 050051, PR China
| | - Hongrui Shen
- Department of Neuromuscular Disease, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang City, Hebei Province, 050051, PR China
| | - Qi Bing
- Department of Neuromuscular Disease, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang City, Hebei Province, 050051, PR China
| | - Nan Li
- Department of Neuromuscular Disease, Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shijiazhuang City, Hebei Province, 050051, PR China
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