Familial hypokalemic periodic paralysis with permanent myopathy. A clinical and ultrastructural study

Measuring quality of life impairment in skeletal muscle channelopathies

Background and purpose

Fatigue and pain have been previously shown to be important determinants for decreasing quality of life (QoL) in one report in patients with non-dystrophic myotonia. The aims of our study were to assess QoL in skeletal muscle channelopathies (SMC) using INQoL (individualized QoL) and SF-36 questionnaires.

Methods

We administered INQoL and SF-36 to 66 Italian patients with SMC (26: periodic paralysis, 36: myotonia congenita and 4: Andersen-Tawil) and compared the results in 422 patients with myotonic dystrophies (DM1: 382; and DM2: 40).

Results

(i) INQoL index in SMC is similar to that in DMs (P = 0.79). (ii) Patients with myotonia congenita have the worst perception of QoL. (iii) Myotonia has the most detrimental effect on patients with myotonia congenita, followed by patients with DM2 and then by patients with DM1 and hyperkalemic periodic paralysis. (iv) Pain is a significant complaint in patients with myotonia congenita, hypokalemic periodic paralysis and DM2 but not in DM1. (v) Fatigue has a similar detrimental effect on all patient groups except for patients with hyperkalemic periodic paralysis in whom muscle weakness and myotonia more than fatigue affect QoL perception. (vi) Muscle symptoms considered in INQoL correlate with physical symptoms assessed by SF-36 (R from −0.34 to −0.76).

Conclusions

QoL perception in patients with SMC is similar to that of patients with DMs, chronic multisystem disabling conditions. Our results provide information to target treatment and health care of these patients. The sensitivity of INQoL to changes in QoL in the SMC needs to be further explored in longitudinal studies.

Familial neuromuscular disease with tubular aggregates

We have studied four members of a family in which five individuals of both sexes in three generations have mild weakness and muscle aching. Serum creatine kinase (CK) and/or aldolase were mildly to moderately elevated. Tubular aggregates were present in all patients in all fiber types. Type 1 fiber predominance and type 2 hypotrophy or atrophy was noted in three biopsies. Fiber splitting was prominent in two cases. Electron microscopic studies confirm that the tubular aggregates originate from muscle sarcoplasmic reticulum (SR). The presence of T tubules making contacts with some tubules inside the collection of tubular aggregates is suggestive of their derivation from terminal cisternae.

Dysferlin expression in tubular aggregates: their possible relationship to endoplasmic reticulum stress

Dysferlin is a newly identified sarcolemmal protein related to Miyoshi myopathy and limb-girdle muscular dystrophy. Although its function is still unknown, it is inferred from the presence of C2 domains and a transmembrane domain in its sequence that dysferlin may be expressed or located not only at the sarcolemma but also in other membranous organelles to interact with Ca(2+). Tubular aggregates (TAs) are derived from sarcoplasmic reticulum (SR) and found in various myopathies, especially in those related to disturbed intra-sarcoplasmic Ca(2+) homeostasis. To clarify the expression of dysferlin in TAs and the relationship among TA formation, dysferlin expression, and endoplasmic reticulum (ER) stress, we examined the expression of dysferlin and other sarcolemmal proteins by immunohistochemistry in 12 muscle biopsy specimens with TAs from 11 cases of periodic paralysis and 1 case of myalgia/cramps syndrome. Moreover, the expression of glucose-regulated protein 78 (GRP78) and GRP94, which are up-regulated under ER stress, was also examined by immunohistochemistry and immunoblotting. TAs showed strong expression of dysferlin. GRP78 and GRP94 were also intensely expressed in TAs. Total amounts of GRP78 and GRP94 were significantly increased in muscles with TAs compared with normal controls. These results indicate that muscles with TAs seem to be under ER stress, probably resulting from disturbed intra-sarcoplasmic Ca(2+) homeostasis. Strong expression of dysferlin in TAs suggests the possibility that it is located not only at the sarcolemma but also in the SR, at least in the pathological conditions.

Spheroid body myopathy revisited

Having reported spheroid body myopathy from Indiana (IN) inherited in an autosomal-dominant fashion several years ago, we now describe additional findings from the Oregon branch--briefly recorded earlier--and confirm earlier studies in another clinically affected IN member of this kinship demonstrating identical spheroid bodies within the myopathic muscle specimens. The spheroid bodies also contained increased amounts of desmin, alpha-B crystallin, and ubiquitin within muscle fibers. Our studies now have established that spheroid body myopathy is a member of the growing family of desminopathic neuromuscular conditions.

Channelopathies: the nondystrophic myotonias and periodic paralyses

The term channelopathy does not indicate a new group of neuromuscular conditions, but a re-orientation of well- and long-known muscular conditions, the congenital myotonias, and the periodic paralyses. Although, in the past, they have overlapped clinically here and there, both groups were classified differently, as myotonias and as metabolic myopathies, respectively. The discovery of mutations in several ion channels has rewritten nosography of these disorders and procured a new term, the channelopathy-clinical, electrophysiological, and molecular genetic details of which are discussed in this chapter.

[Periodic paralysis: anatomo-pathological study of skeletal muscles in 14 patients]

Periodic paralysis is a rare disease, characterized by transient weakness associated with abnormal levels of serum potassium. Muscle biopsy may show a wide range of abnormalities, vacuoles being more specifically linked to the disease. We analysed 17 muscle biopsies from 14 patients with periodic paralysis (14 hypokalemic, 2 hyperkalemic). All of them showed at least one histological abnormality. Fourteen specimens showed vacuoles that were peripheral, single, frequent and preferentially found in type I fibers. Frequency or severity of attacks did not correlate with the presence of vacuoles but those were more easily found in patients with long term disease. Ten biopsies showed tubular aggregates, specially on the patients with frequent crises or long term disease. A second biopsy was done in three patients and in two we observed a worsening of the histopathologic picture. One patient manifested interictal weakness with evident myopathic changes on the muscle biopsy. Nonspecific changes were found in variable degrees in 15 biopsies. Our study shows that vacuoles and tubular aggregates are frequent changes in periodic paralysis and therefore helpful for the diagnosis. Important myopathic findings in the muscle biopsy suggest a permanent myopathy which probably develops after severe crises or long term disease.

Muscle pathology correlates with permanent weakness in hypokalemic periodic paralysis: a case report

We present a morphological follow-up in a case of familial hypokalemic periodic paralysis with progressive weakness. At age 12 years muscle biopsy revealed mild vacuolar changes. Seventeen years later, after the patient had developed permanent weakness, light and electron microscopy disclosed tubular aggregates in about 15% of the fibers and medium-grade myopathic alterations. We describe correlation of muscle pathology with permanent weakness in hypokalemic periodic paralysis.

The syndrome of continuous muscle fibre activity: light and electron microscopic studies in muscle and nerve biopsies

Histological and ultrastructural studies were performed on nerve and muscle biopsy specimens from two patients with the syndrome of continuous muscle fibre activity. The characteristics of muscle biopsies were as follows. By light microscopy, internal nuclei were present in many of the fibres. By electron microscopy many fibres contained filamentous bodies and subsarcolemmal aggregates of mitochondria embedded in the peripheral zone of cytoplasm, and occasional mitochondria with disorganized or branched cristae were larger than normal. Biopsies of sural nerves revealed a decreased number of myelinated fibres, clusters of small myelinated fibres, and evidence of active axonal degeneration such as disintegrated myelin segments and degenerated axon components, as well as loss of axonal contents. With the present biopsy findings, it is suggested that the pathological process of this syndrome affects peripheral nerves as well as muscles.

The MRL +/+ mouse: a new model of tubular aggregates which are gender- and age-related

Congenic mice of the MRL +/+ substrain provide an animal model for study of tubular aggregates in skeletal muscle. Tubular aggregates appear limited only to males of the MRL +/+ strain and are not found in other strains, including MRL +/-, MRL lpr/lpr, BXSB/MpJ, BALB/c, SJL/J, AJ, or C3H HEJ. This strain-specific occurrence, and the gradually increasing abundance of tubular aggregates after 6 months of age until virtually all type II myofibers are affected by 2 years, implies that both genetic and developmental factors are necessary for the occurrence of tubular aggregates. These two factors are not sufficient, however, since hormonal alteration by male castration nearly completely prevents the expression of tubular aggregates. Parallels are drawn with how expression of tubular aggregates is limited largely to males in diverse acquired and hereditary human neuromuscular disorders.

Histochemical features of tubular aggregates in diseased human skeletal muscle fibres

This communication presents the results obtained in tubular aggregates of 24 enzyme histochemical techniques for demonstrating activity of oxidoreductases, transferases, hydrolases and isomerases. The activity characteristics of the tubular aggregates in m. gluteus medius of 18 patients with diseases of the neuromuscular system were almost identical. A high activity of the mitochondrial enzymes, NADPH: tetrazolium oxidoreductase, NADH:tetrazolium oxidoreductase and cytochrome c oxidase, could be shown in the pathological structures, whereas the activity of the mitochondrial enzymes, glycerol-3-phosphate:menadione oxidoreductase, succinate:PMS oxidoreductase, malate:NAD+ oxidoreductase and isocitrate:NAD+ oxidoreductase, and the partial mitochondrial enzymes, malate:NADP+ oxidoreductase and isocitrate:NADP+ oxidoreductase, was very slight or even absent. There was a moderate to strong activity of the glycolytic enzymes lactate:NAD+ oxidoreductase, glyceraldehyde-3-phosphate:NAD+ oxidoreductase, phosphofructokinase, phosphoglucomutase and glucose phosphate isomerase. In contrast, the activity of alpha-glucan phosphorylase was slight. The activity of phosphogluconate:NADP+ oxidoreductase, glucose-6-phosphate:NADP+ oxidoreductase and 5'-nucleotidase was slight, whereas there was no activity of myosin ATPase and mitochondrial ATPase, acid phosphatase or alkaline phosphatase. The high activity of AMP-deaminase was very striking. The activity of peroxidase was moderate. Results obtained with adsorption studies point to adsorption of some of the enzymes studied to the tubular aggregates in vivo and this phenomenon very probably determined the histochemical characteristics of these structures.

Induction of spheroid cytoplasmic bodies in a rat muscle by local tetanus

The term "cytoplasmic body" or "spheroid body" myopathy refers to a heterogeneous group of familial or sporadic diseases characterized primarily by the presence of abundant spheroid or cytoplasmic bodies in the muscles. The morphogenesis of these inclusions remains unclear. This article describes the induction and evolution of spheroid cytoplasmic bodies (SCBs) in the rat plantaris muscle (PL) with local tetanus, which was induced in rats by the injection of a minute amount of tetanus toxin. In contrast to the tetanized soleus muscle (SOL), which developed core fibers (central cores, minicore, target fiber, targetoid fiber, and rods), the tetanized PL produced numerous SCBs with a predictable time course. They were induced in both type 1 and 2 fibers of PL, which is composed predominantly (95%) of type 2 fibers, in contrast to SOL (85% type 1 fibers). Factors inducing SCBs may include immobilization, shortening, intact innervation, and disuse atrophy.

Thyrotoxic periodic paralysis

A case of thyrotoxic periodic paralysis is reported in a Hispanic man with an unusual recurrence six weeks after radioactive iodine treatment. Thyrotoxic periodic paralysis has now been well characterized in the literature: it occurs primarily in Orientals with an overwhelming male preponderance and a higher association of specific HLA antigens. Clinical manifestations include onset after high carbohydrate ingestion or heavy exertion, with progressive symmetric weakness leading to flaccid paralysis of the extremities and other muscle groups, lasting several hours. If hypokalemia is present, potassium administration may help abort the attack. Although propranolol can be efficacious in preventing further episodes, the only definitive treatment is establishing a euthyroid state. The pathophysiology is still controversial, but reflects altered potassium and calcium dynamics as well as certain morphologic characteristics within the muscle unit itself.

Tubular aggregates: their association with myalgia

Three thousand consecutive muscle biopsies were reviewed for the presence of tubular aggregates and their association with clinical symptomatology. Tubular aggregates were detected in 19 patients (0.6%). Twelve of these nineteen patients had severe myalgia, and the most abundant tubular aggregates were found in biopsies of patients with myalgia. Seven patients had only myalgia as their clinical symptomatology with normal physical examination. An additional five patients with tubular aggregates and myalgia had concomitant amyotrophic lateral sclerosis (2) or neuropathy (3). The high incidence of myalgia associated with tubular aggregates in our patients and the fact that tubular aggregates originate from sarcoplasmic reticulum suggest a role played by this structure in the pathogenesis of myalgia.

Intracytoplasmic inclusions in the atrophic muscle fibers in Werdnig-Hoffmann disease

In the biopsied muscle from a male infant having clinical and pathological characteristics of Werdnig-Hoffmann disease, unusual intracytoplasmic inclusions measuring from 1.5-7 micron in dimension were observed in approximately 3% of the atrophic fibers. Although the ultrastructural characteristics of the inclusion were almost identical to that of "cytoplasmic body" seen in various neuromuscular disorders, which showed somewhat different histochemical reactions. This unusual structure was assumed to have originated from degenerated myofibrils and possibly from mitochondria, while the significance of the body formation still remains to be solved.

A new myopathy with tubulomembranous inclusions

A muscle biopsy performed on a 16-year-old boy with progressive myopathy revealed hitherto unrecognized peculiar inclusions which consisted of 3 types of structures. The first type consisted of laminated tubulomembranous structures and most of the inclusions belonged to this type. The lamellae were regularly spaced with a periodicity of 8.5--9 nm and curving a little, and were observed as concentric lamellae according to the plane of sectioning. The second type of inclusions consisted of curvifilamentous material. The third type had the appearance of moderately electron-dense granular material surrounded by a single unit membrane. The origin and nature of these inclusions is obscure, but the diagnosis of some kind of storage myopathy was suspected in this case.

Subsequent morphological changes in periodic paralysis. A study of seven cases

Muscle biopsies were studied in seven patients with various types of periodic paralysis. A sequence for the histopathological feature is suggested: 1. Histology may be normal early in the disease. 2. Vacuolation is found during the active phase characterized by frequent attacks. 3. Tubular aggregates appear later when the frequency of the attacks decreases. 4. Degenerative changes are correlated with the presence of permanent myopathic weakness.

Case report. Ultrastructural changes of muscles during attacks of adynamia episodica hereditaria

In an ultrastructural study of biopsies of quadriceps femoris muscle from two patients during attacks of adynamia episodica hereditaria. Marked pinocytosis along the sarcolemma and an interfibrillary oedema were observed, together with a 'bamboo-like' shape of the myofibrils. Other non-specific abnormalities were also found.

Tubular aggregates in murine dystrophy heterozygotes

Heterozygous dystrophic mice (strain 129 ReJ dy/+) were studied to determine the morphological changes that are characteristic of the heterozygote state. The morphology of the muscle in 35 heterozygotes (+/?) was compared with that of 35 homozygotes (dy/dy) and 20 normal controls (+/+). Muscle was examined with light microscopy, standard histochemical techniques, and electron microscopy. Few abnormalities were detected with light microscopy or with histochemistry. With electron microscopy, some slight nonspecific evidence of muscle damage in the form of focal myofibrillar degeneration was seen in all of the heterozygotes. The striking abnormality, however, was the presence of tubular aggregates in type 2 fibers in 60% of the heterozygotes. Tubular aggregates were not found in homozygous dystrophic mice or in normal controls. The significance of this finding is discussed and it is suggested that tubular aggregates may represent lateral sac dilatation and infolding.

Neuropathy and mitochondrial myopathy

It has been stated that peripheral neuropathy can be a feature of so-called ophthalmoplegia-plus syndrome, but to date only one case of hypertrophic neuropathy has been reported. This study is concerned with the clinical, electrophysiological, and pathological observations in a 37-year-old man with progressive external ophthalmoplegia and a ragged-red fiber myopathy associated with severe sensorimotor neuropathy. Histological and morphometric studies of the sural nerve revealed a marked loss of large myelinated fibers and an occasional degenerating axon. Residual fibers had disproportionately thin myelin sheaths in relation to axon calibers. In contrast to the muscle biopsy findings, no mitochondrial paracrystalline inclusions were observed in the nerve. However, the number of mitochondria per square micron of Schwann cell cytoplasm was elevated when compared with values obtained from normal subjects and a patient with a chronic neuropathy. These findings may indicate an alteration of mitochondrial function common to muscle fibers and Schwann cells which, in nerves, could lead to axon loss and abnormality of myelination.

Rimmed vacuoles

Rimmed vacuoles (Dubowitz and Brooke 1973) have been found in 12 cases with various neuromuscular diseases and are considered to be autophagic in nature. They consisted of multilaminated membranous structures accompanied by glycogen granules, dense bodies, and amorphous, granular, and fibrillar material. The contents of the vacuoles were regarded as having partially dissolved out of the vacuoles in cryostat sections but some were plastered along the walls of the vacuoles and were depicted by the staining procedures for light microscopy. The "lined vacuoles" described by Carpenter et al. (1978) in inclusion body myositis closely agree with the rimmed vacuoles in respect of histochemical and ultrastructural features.

Modifications in the sarcoplasmic reticulum and subcellular calcium distribution in skeletal muscle in a case of Westphal's disease (hypokalemic periodic paralysis)

In a case of hypokalemic periodic paralysis with characteristic alterations of the sarcoplasmic reticulum (SR) in the skeletal muscle, subcellular calcium re-partition, as revealed with the pyroantimonate technique, appears disturbed during paralysis. Pyroantimonate precipitates, normally concentrated in the terminal cisternae of the SR, were localized in the T tubules, whereas the terminal cisternae appeared empty. The increase (about 14%) in muscular calcium during paralysis may result from the accumulation of calcium in the extracellular compartment (T tubules). Defects in calcium uptake and storage by the SR may be involved in the pathogenesis of the periodic paralysis syndrome.

[Thyrotoxic periodic paralysis. Report of a case]

A case of thyrotoxic periodic paralysis based on clinical grounds, laboratory data and therapeutic response as well is reported. The authors comment on the differential diagnosis with the most frequent types of periodic paralysis. The importance of a correct diagnosis and treatment as early as possible is stressed as to prevent further development of permanent paralysis due to irreversible degenerative myofibril changes as stated in literature.

Experimental hypokalemia: ultrastructural changes in rat gastrocnemius muscle

Early ultrastructural changes are studied in rat gastrocnemius muscle during experimental hypokalemia. Vacuolization of muscle fibers is shown to originate in the terminal cisterns of the triads. Important degenerative changes are present in peripheral axons and neuromuscular junctions.

Myopathy with hyperaldosteronism. An electron-microscopic study

In the case reported, an overproduction of aldosterone was accompanied by paretic attacks, a decrease in the serum potassium level, and in muscle tone and the deep tendon reflexes. The decrease of serum potassium level was consistent, but moderate, being to just below the normal lower limit. Loading with carbohydrate produced an attack, forearm ischaemic exercise resulted in less lactic acid production than normally. In the limb-girdle muscles there was also evidence of slight but permanent weakness. The results of histological and ultrastructural examination of a muscle biopsy are reported. It seems probable that the disturbance in the mineralo-corticoid metabolism led periodically to a decrease in the serum potassium, while in some muscle fibres the glycogen content increased and the SR became dilated and partially destroyed. In the attack-free periods tubular aggregates were produced, supposedly through an attempt at regeneration of the SR. During attacks portions of the muscle fibres were destroyed irreversibly and in consequence moderate permanent weakness resulted. Some spheromembranous degradation products which were observed might be regarded as remnants of degenerated tubular aggregates.

Histochemistry and electron microscopy of muscle fibres in a case of congenital paramyotonia

In a case of congenital paramyotonia a muscle biopsy was performed and studied morphologically, histochemically and ultrastructurally. A clearcut pattern of changes has been observed with ATPase and oxidative enzymes. On electron microscopy special changes known as "tubular aggregates" were found. The relationship between the two findings, as well as the significance of such alterations in the range of periodic paralyses and myotonic phenomena, are discussed.

Clinical and ultrastructural observations in a kindred with normo-hyperkalaemic periodic paralysis

Electron microscopic studies of muscle biopsies from clinically unaffected sibs in a family with normo-hyperkalaemic periodic paralysis with variable myotonia have revealed dilatation of the sarcoplasmic reticulum similar to that observed in affected members. This supports the view that such dilatation is not only a significant and likely primary ultrastructural change but that it may precede clinical manifestations and represent an anatomical marker of the genetic trait. Identical dilatation of the sarcoplasmic reticulum was found in the clinically unaffected father of the affected and unaffected grandchildren of the propositus. This raises the possibility that this non-consanguineous member contributed to the genetic trait or its manifestations in the grandchildren of the index patient since similar dilatation of the sarcoplasmic reticulum was not observed in the muscles of healthy control subjects.

Fine structure of rat intrafusal muscle fibers. The equatorial region

An ultrastructural study has been undertaken on the equatorial (sensory) region of the rat muscle spindle. Two kinds of intrafusal muscle fibers, a nuclear bag fiber and a nuclear chain fiber, have been identified in this region on the basis of fiber diameter, nuclear disposition, and M-band appearance. The large-diameter nuclear bag fiber contains an aggregation of tightly packed vesicular nuclei, while the small-diameter nuclear chain fiber contains a single row of elongated, well-separated nuclei. Both muscle fibers contain an attenuated peripheral cylinder of myofilaments surrounding a central core of sarcoplasm. Elements of the sarcotubular system, dilatations of the sarcoplasmic reticulum, and the presence of other sarcoplasmic organelles and inclusions are considerably more abundant in the nuclear chain fiber than in the nuclear bag fiber. Leptomeric organelles and membrane-bounded sarcoplasmic granules are present in both intrafusal fiber types and may be situated between the myofibrils or in intimate association with the sarcolemma. The functional significance of some of these structural findings is discussed.