Evidence of malignant hyperthermia in patients administered triggering agents before malignant hyperthermia susceptibility identified: missed opportunities prior to diagnosis.

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.

Administration of anaesthetic triggering agents to patients tested malignant hyperthermia normal and their relatives in New Zealand: an update.

Testing for malignant hyperthermia in New Zealand involves two tests-in vitro contracture testing of excised lateral quadriceps muscle and DNA analysis. In vitro contracture testing is regarded as the gold standard in malignant hyperthermia diagnosis but several publications have questioned the reliability of a normal result. Analysis of 479 anaesthetic records in 280 patients or their descendants throughout New Zealand who had tested negative for malignant hyperthermia, demonstrated there was no evidence of malignant hyperthermia episodes in this group who had been administered anaesthetic triggering agents. A wide range of anaesthetics were used over the study period. Analysis of each anaesthetic record was undertaken using the malignant hyperthermia grading scale which determines the likelihood that an anaesthetic event represents a malignant hyperthermia episode. Confirmation of the negative results was further supported by normal DNA analysis of patients in 48% of anaesthetics. There are advantages to using inhalational agents in certain situations and although demonstrating a zero risk of a malignant hyperthermia episode is not statistically possible, evidence in this large series suggests that the risk of an episode in these patients is extremely low and may be negligible. We suggest that anaesthetic triggering agents can be used safely in patients with normal in vitro contracture tests, and in their descendants.

Assessing the pathogenicity of RYR1 variants in malignant hyperthermia.

BACKGROUND: . Missense variants in the ryanodine receptor 1 gene ( RYR1 ) are associated with malignant hyperthermia but only a minority of these have met the criteria for use in predictive DNA diagnosis. We examined the utility of a simplified method of segregation analysis and a functional assay for determining the pathogenicity of recurrent RYR1 variants associated with malignant hyperthermia. METHODS: . We identified previously uncharacterised RYR1 variants found in four or more malignant hyperthermia families and conducted simplified segregation analyses. An efficient cloning and mutagenesis strategy was used to express ryanodine receptor protein containing one of six RYR1 variants in HEK293 cells. Caffeine-induced calcium release, measured using a fluorescent calcium indicator, was compared in cells expressing each variant to that in cells expressing wild type ryanodine receptor protein. RESULTS.: We identified 43 malignant hyperthermia families carrying one of the six RYR1 variants. There was segregation of genotype with the malignant hyperthermia susceptibility phenotype in families carrying the p.E3104K and p.D3986E variants, but the number of informative meioses limited the statistical significance of the associations. HEK293 functional assays demonstrated an increased sensitivity of RyR1 channels containing the p.R2336H, p.R2355W, p.E3104K, p.G3990V and p.V4849I compared with wild type, but cells expressing p.D3986E had a similar caffeine sensitivity to cells expressing wild type RyR1. CONCLUSIONS: . Segregation analysis is of limited value in assessing pathogenicity of RYR1 variants in malignant hyperthermia. Functional analyses in HEK293 cells provided evidence to support the use of p.R2336H, p.R2355W, p.E3104K, p.G3990V and p.V4849I for diagnostic purposes but not p.D3986E.

Comparison of pathogenicity prediction tools on missense variants in RYR1 and CACNA1S associated with malignant hyperthermia.

BACKGROUND: Malignant hyperthermia (MH) is a pharmacogenetic disorder that has been linked to the skeletal muscle calcium release channel (RYR1) and the α1S subunit of the voltage-dependent L-type calcium channel (CACNA1S). Genomic DNA capture and next generation sequencing are becoming the preferred method to identify mutations in these genes. Bioinformatic pathogenicity prediction of identified variants may help to determine if these variants are in fact disease causing. METHODS: Eight pathogenicity prediction programmes freely available on the web were used to determine their ability to correctly predict the impact of a missense variant on RyR1 or dihydropyridine receptor (DHPR) protein function. We tested MH-causative variants, variants that had been shown to alter calcium release in cells, and common sequence variants in RYR1 and CACNA1S. RESULTS: None of the prediction programmes was able to identify all of the variants tested correctly as either 'damaging' (MH-causative variants, variants that had been shown to alter calcium release in cells) or as 'benign' (common sequence variants). The overall sensitivity of predictions ranged from 84% to 100% depending on the programme used, with specificity from 25% to 83%. CONCLUSIONS: In this study we determined the sensitivity and specificity of bioinformatic pathogenicity prediction tools for RYR1 and CACNA1S. We suggest that the prediction results should be treated with caution, as none of the programmes tested predicted all the variants correctly and should only be used in combination with other available data (functional assays, segregation analysis).

Safe duration of postoperative monitoring for malignant hyperthermia patients administered non-triggering anaesthesia: an update.

The postoperative care of malignant hyperthermia (MH) patients is subject to international variation, with a paucity of data in the literature to guide management. Over a series of three studies, our aim was to evaluate whether MH-susceptible patients (and relatives who had not yet been investigated), who had received a non-triggering anaesthetic, could be managed in the same way as the standard surgical population. Following a retrospective study, 206 anaesthetics were administered in a prospective second study to MH-susceptible/related individuals who were monitored for a minimum of one hour in the post anaesthesia care unit and a further 90 minutes in a step-down facility. No problems relating to MH were encountered. The postoperative monitoring time was subsequently changed and, in a third study, patients were managed no differently from standard surgical patients. One hundred and twenty-five anaesthetics were administered with no evidence of problems. This data shows that standard postoperative monitoring times are safe and appropriate in MH-susceptible patients.

Sequence capture and massively parallel sequencing to detect mutations associated with malignant hyperthermia.

BACKGROUND: Malignant hyperthermia (MH) is a potentially fatal pharmacogenetic disorder in which intracellular calcium homeostasis in the skeletal muscle of susceptible individuals is disrupted upon exposure to halogenated anaesthetics. While MH is linked to the ryanodine receptor (RYR1) on chromosome 19 and the α1S subunit of the voltage-dependent L-type calcium channel (CACNA1S) on chromosome 1, mutations have been found in only 50-70% of patients, and subsequently, there is a need for a more powerful screening tool. METHODS: Genomic DNA capture and next-generation sequencing was used to screen 32 genes involved in excitation-contraction coupling, skeletal muscle calcium homeostasis, or immune response in two MH patients. Lymphoblastoid cell lines were used to functionally characterize candidate RYR1 mutations in one family. RESULTS: Sequence analysis revealed two putative causative mutations in RYR1 in one patient. Segregation analysis and functional analysis support a causative role of the detected variants. The amount of Ca(2+) released after stimulation with 4-chloro-m-cresol from B lymphocytes of the MH-susceptible patients in the family was significantly greater compared with that of Ca(2+) released from cells of an MH-negative family member. In the other patient, no causative mutations were identified in the 32 genes screened. CONCLUSIONS: In this study, we successfully demonstrate the use of genomic DNA capture and next-generation sequencing for identification of putative mutations causing MH. We also suggest that whole exome sequencing may be necessary to identify MH causing mutations in patients where no mutations in RYR1 and CACNA1S have been identified thus far.

Safety of exposure of malignant hyperthermia non-susceptible patients and their relatives to anaesthetic triggering agents.

As the reliability of malignant hyperthermia normal in vitro contracture test results has been questioned, this study set out to determine the reliability of malignant hyperthermia normal results in New Zealand. Three hundred and twenty-nine anaesthetics were administered to malignant hyperthermia normal patients, identified through the Palmerston North Hospital malignant hyperthermia database. Anaesthetic records were retrieved and scrutinised for a malignant hyperthermia reaction using the Malignant Hyperthermia Clinical Grading Scale. Patients were exposed to one or more of eight triggering agents and multiple anaesthetic agents were administered in 41% of cases. Six variables were analysed, and although a minority of variables were abnormal in a small number of patients, none of the findings supported a malignant hyperthermia reaction. While the analysis was limited by the adequacy of the anaesthesia records, it was supported by negative DNA analysis in 55% of patients. This study supports several previous studies in demonstrating that patients in New Zealand tested non-susceptible to malignant hyperthermia can safely be given triggering agents.

Normal vitamin D receptor function with increased expression of 25-hydroxyvitamin D(3)-24-hydroxylase in Corriedale sheep with inherited rickets.

A likely inherited disease with gross and microscopic features of rickets has been recognised in Corriedale sheep in New Zealand, and a defect in end-organ responsiveness to vitamin D has been proposed as a likely mechanism. The aim of the present study was to characterize the mode of inheritance and determine the disease mechanism. Breeding trials showed that the mode of inheritance was autosomal recessive. Serum chemistry testing using different methodology and studies in cultured skin fibroblasts did not support our previous hypothesis of a defect in end-organ responsiveness. The studies revealed normal serum 1,25-dihydroxyvitamin D concentrations, normal vitamin D receptor function, and the presence of 24-hydroxylase mRNA in cells from affected sheep, even without induction by 1,25-dihydroxyvitamin D(3). In addition, osteocalcin mRNA expression was similar in both affected and control sheep. It was concluded that increased expression of 25-hydroxyvitamin D(3)-24-hydroxylase, the enzyme that breaks down vitamin D, may be involved in the pathogenesis of inherited rickets in Corriedale sheep, but its role requires further clarification.

Malignant hyperthermia and day stay surgery.

Patients who are malignant hyperthermia susceptible are often admitted overnight for observation, even after minor surgery. They may be declined care in a stand-alone day stay unit. This prospective audit set out to investigate whether patients susceptible to malignant hyperthermia can be safely treated as day stay patients. The audit was conducted for four years from late 2000. All patients who were known to be susceptible to malignant hyperthermia, and their untested relatives, who received day stay anaesthesia were included in the audit. Malignant hyperthermia status, age, duration of anaesthesia, anaesthetic technique, type of procedure, intraoperative and postanaesthesia care unit observations and complications were recorded. All patients received a trigger-free anaesthetic technique. Detailed postanaesthesia care unit monitoring was undertaken and patients were observed for two and a half hours postoperatively. Seventy-two patients were included in the audit. General anaesthesia was administered to 85% and regional to 15%. Only minor complications arose in the postoperative period, and none suggested a malignant hyperthermia reaction. Postanaesthesia care unit nursing staff contacted 49 (68%) of the patients the following day, and there was no evidence of malignant hyperthermia reactions. This audit suggests that malignant hyperthermia susceptible patients can be safely managed as day stay patients in appropriate facilities, with appropriate postoperative care.

Neospora caninum: quantification of DNA in the blood of naturally infected aborted and pregnant cows using real-time PCR.

This study quantified Neospora caninum DNA in the blood and brain of pregnant and aborted heifers by monitoring PCR product formation in real-time using SYBR Green I, a double-stranded DNA-binding dye. Primers were designed to amplify a 188 bp product specific to N. caninum from the Nc-5 gene fragment of N. caninum. Similarly, a 71 bp product was amplified from the 28S rRNA gene of bovine genomic DNA that served as a control. Agarose gel electrophoresis and analysis of the melting curve for PCR products showed that both primer pairs were specific to their targets. Standard curves were generated for both bovine and N. caninum genomic DNA, and were used to compute the relative concentration of parasite to bovine DNA in the test samples. The concentration of N. caninum DNA in 1 ng of bovine genomic DNA obtained from blood ranged between 0.097 ng at the 1st week of the observation and 0 ng at the 15th week in aborted cows. In pregnant cows, the values ranged between 0.080 ng at the 1st week and 0.155 ng at the 15th week of observation. There was a sustained decrease of DNA concentration in the aborted group after abortion and an increase in DNA concentration in the pregnant group. Comparison of parasite DNA in blood and brain of infected heifers showed a higher DNA concentration in brain than in blood. This study shows that N. caninum DNA can be quantified to obtain the relative concentration of parasite DNA to host genomic DNA in blood. This technique allows testing of a large number of samples at one time and can be done without the need for slaughter of tested animals.

Recognition patterns of Neospora caninum tachyzoite antigens by bovine IgG at different IFAT titres.

This study describes qualitative and quantitative antibody response in cows naturally infected with Neospora caninum. The study was carried out with 269 serum samples obtained from 24 cows over a period of 15 weeks. Prior to sample collection, the cows were tested with ELISA. The 269 samples were screened with IFAT and categorized into seven IFAT titre groups (< 1 : 80, 1 : 80, 1 : 200, 1 : 600, 1 : 1000, 1 : 2000, > 1 : 2000). The samples were finally analysed by Western blotting. Seven immunodominant antigens (approximately 18-, approximately 25-, approximately 33-, approximately 35-36-, approximately 45-46-, approximately 47-, approximately 60-62 kDa) and five minor antigens (approximately 25, approximately 51, approximately 64, approximately 77, approximately 116 kDa) were recognized by cow sera. The recognition of approximately 46 kDa antigen by cow sera was common to samples with IFAT titre 1 : 80 and above. Another common antigen was the approximately 18 kDa antigen, which was recognized by samples with IFAT titre 1 : 200 and above. The most remarkable observation was the presence of the 45-46 kDa, the 77 kDa, and absence of the 18 kDa antigenic bands in samples with IFAT titre 1 : 80. This observation was consistent even in the face of fluctuating antibody titre where serum antibody titres from an animal exceeded then failed to reach 1 : 80. Antibody fluctuation was observed across all cows (pregnant and aborted) with no discernible fluctuation pattern. However, the fluctuation in antibody titre observed appeared to be most remarkable in initially ELISA-negative pregnant cows, and to a lesser extent in ELISA-positive pregnant cows, and ELISA-positive aborted cows. Although there was fluctuation in antibody titre, the banding patterns of N. caninum tachyzoite antigens by cows within the same IFAT titre group remained similar.

The use of PCR to detect Neospora caninum DNA in the blood of naturally infected cows.

Twelve 2-year old heifers in their fifth month of gestation when pregnancy tested were used in this study. Six heifers aborted at approximately 4 months of gestation and had blood samples drawn less than 6 weeks after the abortions were identified. Blood samples were also drawn from three sero-positive pregnant and three sero-negative pregnant heifers. DNA was isolated from the samples and a 350 bp fragment of the Nc-5 gene was PCR amplified using primer pair Np21+ and Np6+. Also, the Internal Transcribed Spacer 1 (ITS1) was PCR amplified using Tim 3 and Tim 11 primer pair. The Nc-5 gene fragment was cloned, sequenced and the sequence BLAST-tested. Similarly, the ITS1 product was sequenced and BLAST-tested. The BLAST test results revealed that Neospora caninum DNA was present in these blood samples indicating that polymerase chain reaction can be used in the detection of N. caninum DNA in the blood of sero-positive cows.

Safe duration of postoperative monitoring for malignant hyperthermia susceptible patients.

Postoperative management of malignant hyperthermia (MH) susceptible patients has changed substantially over the last 20 years, with many patients now managed as day cases. Our previous policy was to monitor known MH susceptible patients (and relatives of known MH susceptible individuals not yet investigated by muscle biopsy) for four hours in the Post Anaesthetic Care Unit. However, anaesthetic literature reports suggest that MH reactions usually commence within one hour of anaesthesia. For this reason we conducted a retrospective review of Post Anaesthetic Care Unit data in 254 MH susceptible/related patients treated between 1991 and late 2000. On the basis of this review we instituted a policy change and reduced our monitoring time to one hour in the Post Anaesthetic Care Unit with a further 1.5h in a step-down unit if indicated. A prospective study in a further 68 MH susceptible/related patients showed that no MH reactions were missed due to the shorter monitoring period.

Isolation and molecular characterisation of Neospora caninum in cattle in New Zealand.

AIM: To isolate Neospora caninum from the brains of naturally infected cattle and use molecular techniques to characterise the isolates. METHODS: Neospora caninum tachyzoites were isolated in Vero cell culture from the brains of a cow and two calves. The isolates were characterised using polymerase chain reaction (PCR) methods, DNA sequencing, an immunofluorescent antibody test (IFAT), transmission electron microscopy (TEM), and immunohistochemistry (IHC). The brains of the three cattle were subjected to histopathological examination. A pathogenicity study was conducted in 120 BALB/c mice. RESULTS: Neospora caninum tachyzoites were isolated from all three cases and first observed in vitro between 14 and 17 days post-inoculation. Parasites were sub-cultured and maintained in Vero cell culture for more than 6 months. PCR products were generated for all three isolates, using two different primers. Sequencing of the PCR products and a subsequent BLAST search identified the isolates as N. caninum. In addition, the isolates tested positive using IFAT and IHC, and ultrastructure revealed by TEM was characteristic of N. caninum. Histopathological examination revealed lesions characteristic of N. caninum in 1/3 brains. In the pathogenicity study using BALB/c mice, the mortality rate was 3-7%. CONCLUSION: This was the first successful isolation of N. caninum in New Zealand confirmed using molecular characterisation tests.

Suspected malignant hyperthermia reactions in New Zealand.

Early clinical signs, triggering agents, time to onset of reaction, mortality and methods of treatment were identified in 123 suspected malignant hyperthermia reactions. In vitro contracture test results were compared with clinical signs and the Malignant Hyperthermia Clinical Grading Scale. Increased end-tidal carbon dioxide is the earliest sign when not preceded by masseter spasm. Earlier diagnosis reduces the incidence of rigidity and severe metabolic acidosis. The combination of suxamethonium and a potent volatile anaesthetic agent triggers an earlier reaction compared with a volatile agent alone. There has been zero mortality since 1981, essentially due to a combination of advanced monitoring capability, increased anaesthetist awareness of malignant hyperthermia, and dantrolene availability. DNA analysis has identified nine New Zealand families with ryanodine receptor gene mutations. A positive DNA test indicates malignant hyperthermia susceptibility with "causative" mutations but discordance requires that negative DNA tests are confirmed with in vitro contracture test. This test also demonstrated the shortcomings of the Malignant Hyperthermia Clinical Grading Scale.