Hereditary aspects of malignant hyperthermia

Opportunities and Challenges in Cardiovascular Pharmacogenomics: From Discovery to Implementation

This review will provide an overview of the principles of pharmacogenomics from basic discovery to implementation, encompassing application of tools of contemporary genome science to the field (including areas of apparent divergence from disease-based genomics), a summary of lessons learned from the extensively studied drugs clopidogrel and warfarin, the current status of implementing pharmacogenetic testing in practice, the role of genomics and related tools in the drug development process, and a summary of future opportunities and challenges.

Methods for optimizing statistical analyses in pharmacogenomics research

Pharmacogenomics is a rapidly developing sector of human genetics research with arguably the highest potential for immediate benefit. There is a considerable body of evidence demonstrating that variability in drug-treatment response can be explained in part by genetic variation. Subsequently, much research has ensued and is ongoing to identify genetic variants associated with drug-response phenotypes. To reap the full benefits of the data we collect we must give careful consideration to the study population under investigation, the phenotype being examined and the statistical methodology used in data analysis. Here, we discuss principles of study design and optimizing statistical methods for pharmacogenomic studies when the outcome of interest is a continuous measure. We review traditional hypothesis testing procedures, as well as novel approaches that may be capable of accounting for more variance in a quantitative pharmacogenomic trait. We give examples of studies that have employed the analytical methodologies discussed here, as well as resources for acquiring software to run the analyses.

Denaturing High Performance Liquid Chromatography Screening of Ryanodine Receptor Type 1 Gene in Patients with Malignant Hyperthermia in Taiwan and Identification of a Novel Mutation (Y522C)

We performed the present study to identify the mutation in patients in Taiwan with malignant hyperthermia (MH). We also test the hypothesis that a denaturing high-performance liquid chromatography (DHPLC) protocol can be used for mutation detection in these patients. We identified five Taiwanese patients with typical clinical presentations of MH after general anesthesia. We also enrolled 50 healthy volunteers. Polymerase chain reaction was used to amplify the ryanodine receptor (RYR1) gene mutation hot spots and DHPLC techniques were used to screen for mutations. Upon detection of a heterozygous elution pattern in DHPLC analysis, DNA sequencing reaction was performed to identify the nucleotide variations. We identified a RYR1 mutation in all 5 patients with MH. There were 4 different mutations in the 5 patients: Tyr522Cys, Arg552Trp, Val2168Met, and Thr2206Arg. Among the 5 patients, 2 unrelated patients had the same Thr2206Arg mutation. Three of the mutations had been reported before, but the Tyr522Cys mutation was novel. None of the MH-related mutations were found in the control group. In conclusion, we identified RYR1 mutations in 5 Taiwanese patients with MH using a DHPLC-based approach. A DHPLC-based genetic test may be developed as a noninvasive and convenient test for MH.

Intracellular ionized calcium concentration in muscles from humans with malignant hyperthermia

Ca2+ selective microelectrodes have been used to determine the free myoplasmic [Ca2+] in human skeletal muscle obtained from patients who had developed early signs associated with malignant hyperthermia (MH) during anesthesia. Intercostal muscle biopsies were performed under local anesthesia in four MH patients 15 days to 4 months after developing the MH crisis and in three control subjects. We used only microelectrodes that showed a Nernstian response between pCa3 and pCa7 (30.5 mV per decade at 37 degrees C). Membrane resting potential (V(m)) and calcium potential (V(Ca)) were obtained from superficial fibers. The free cytosolic [Ca2+] was 0.39 +/- 0.1 microM (mean +/- SEM, n = 18) in muscle fibers obtained from malignant hyperthermic patients, whereas in control subjects it was 0.11 +/- 0.02 microM (n = 10). These results suggest that this syndrome might be related to an abnormally high myoplasmic free resting calcium concentration, probably due to a defective function of the plasma membrane or the sarcoplasmic reticulum.

A note on the relevance of human population genetic variation and molecular epidemiology to assessing radiation health risk for space travellers

We discuss the relevance to space medicine of studies concerning human genetic variation and consequent variable disease susceptibility or sensitivity between individuals. The size of astronaut and cosmonaut populations is both presently and cumulatively small, and despite the launch of the International Space Station, unlikely to increase by orders of magnitude within the foreseeable future. In addition, astronauts-cosmonauts constitute unrepresentative samples of their national populations. While the context of exposure for the astronaut-cosmonaut group is one unlikely to be replicated elsewhere than in space, aspects of specific exposures may be simulated by events such as occupational radiation exposure or radiation therapy. Hence, population-based studies of genetic susceptibility or sensitivity to disease, especially where it is precipitated by events that may simulate consequences of the space environment, likely will prove of value in assessing long-term health risks.

Differential diagnosis of thyroid crisis and malignant hyperthermia in an anesthetized porcine model

The intra-operative differential diagnosis between thyroid crisis and malignant hyperthermia can be difficult. Also stress alone can trigger MH. The purposes of this study were: 1) to investigate the metabolic and hemodynamic differences between thyroid crisis and MH, 2) determine how thyroid crisis affects the development of MH, and 3) determine if the stress of thyroid crisis can trigger MH in susceptible individuals. We studied MH susceptible and normal swine. Two groups of animals (MH susceptible and normal) were induced into thyroid crisis (critical core hyperthermia, sustained tachycardia and increase in oxygen consumption) by pretreatment with intraperitoneal triiodothyronine (T3) followed by large hourly intravenous injections of T3. Two similar groups were given intravenous T3 but no pretreatment. These animals did not develop thyroid crisis and served as controls. Thyroid crisis did not result in metabolic changes or rigidity characteristic of an acute episode of MH. When the animals were subsequently challenged with MH triggering agents (halothane plus succinylcholine) dramatic manifestations of fulminant MH episodes (acute serious elevation in exhaled carbon dioxide, arterial CO2, rigidity and acidemia) were noted only in the MH susceptible animals. Although thyroid crisis did not trigger MH in the susceptible animals it did decrease the time to trigger MH (14.1 +/- 7.2 minutes versus 47.2 +/- 17.7 minutes, p < 0.01) in susceptible animals. Hormone induced elevations in temperature and possibly other unidentified factors during thyroid crisis may facilitate the triggering of MH following halothane and succinylcholine challenge.

Influence of heredity on human sensitivity to environmental chemicals

Hereditary peculiarities in individual responses to environmental chemicals are a common occurrence in human populations. Genetic variation in glutathione S-transferase, CYP1A2, N-acetyltransferase, and paraoxonase exemplify the relationship of metabolic variation to individual susceptibility to cancer and other toxicants of environmental origin. Heritable receptor protein variants, a subset of proteins of enormous pharmacogenetic potential that have not thus far been extensively explored from the pharmacogenetic standpoint, are also considered. Examples of interest that are considered include receptor variants associated with retinoic acid resistance in acute promyelocytic leukemia, with paradoxical responses to antiandrogens in prostate cancer, and with retinitis pigmentosa. Additional heritable protein variants of pharmacogenetic interest that result in antibiotic-induced deafness, glucocorticoid-remediable aldosteronism and hypertension, the long-QT syndrome, and beryllium-induced lung disease are also discussed. These traits demonstrate how knowledge of the molecular basis and mechanism of the variant response may contribute to its prevention in sensitive persons as well as to improved therapy for genetically conditioned disorders that arise from environmental chemicals.

Malignant Hyperthermia

Malignant hyperthermia (MH) is a rare, genetically inherited hypermetabolic syndrome that remains dormant until triggered by exposure to certain conditions (emotional and physical stresses) or pharmacological agents (anesthetic gases and succinylcholine) in susceptible individuals. It is believed that MH is caused by a derangement in the control of intracellular calcium ions, which results in a hypermetabolic state from sustained muscle contractures. Without supportive measures and immediate treatment with the antidote, dantrolene, the mortality rate from MH can be as high as 70%. A complete personal and family medical history before surgery can show important clues that might alter the anesthetic regimen preoperatively and postoperatively (eg, the use of nontriggering agents) in MH-susceptible patients. Anesthesia personnel need to recognize the early signs of a MH crisis (eg, tachycardia, muscle stiffness, hypercapnia, and tachypnea), then monitor for other signs (eg, arrhythmias, blood pressure changes, fever, metabolic and respiratory acidosis, and mottling cyanosis), and initiate prompt treatment. Because immediate recognition and treatment of this potentially fatal hyperpyrexic episode increase a patient's chance of survival, other health care personnel (eg, nurses, pharmacists) play key roles in the emergency treatment of a MH crisis. A suspected episode of MH should be followed up with contracture testing to determine MH susceptibility (MHS). Reports of MH should be reported to the North American MH Registry.

Diagnosis of susceptibility to malignant hyperthermia with flanking DNA markers

OBJECTIVE

To define the region on human chromosome 19 carrying the gene for malignant hyperthermia susceptibility and to evaluate the use of flanking DNA markers in diagnosing susceptibility.

DESIGN

Prospective molecular genetic linkage studies in a large malignant hyperthermia pedigree.

SETTING

Irish malignant hyperthermia testing centre.

SUBJECTS

A large Irish malignant hyperthermia pedigree.

MAIN OUTCOME MEASURES

Routine diagnosis of susceptibility to malignant hyperthermia with in vitro contracture test on muscle biopsy specimens and genetic linkage between susceptibility and polymorphic DNA markers in a malignant hyperthermia family.

RESULTS

Genetic typing of polymorphic DNA markers in a large Irish malignant hyperthermia pedigree generated a lod score of greater than 3 for the marker D19S9 and showed that the gene for susceptibility is flanked by the markers D19S9 and D19S16. These tightly linked flanking markers allowed non-invasive presymptomatic diagnosis of susceptibility in five untested subjects in the large pedigree with an accuracy of greater than 99.7%.

CONCLUSIONS

DNA markers flanking the gene for susceptibility to malignant hyperthermia can be used with high accuracy to diagnose susceptibility in subjects in large known malignant hyperthermia pedigrees and may replace the previous in vitro contracture test for diagnosing this inherited disorder in large families with malignant hyperthermia.

Kinase activity and protein phosphorylation in control and malignant hyperthermic skeletal muscle

1. Native 6% Laemmli gels were used to resolve 7 protein kinase activity bands in control and malignant hyperthermia (MH)-susceptible porcine and human skeletal muscle extracts. 2. MH-susceptible samples were consistently more active than the controls. 3. Following halothane treatment, a 43 kDa component displayed increased phosphorylation by a calcium-calmodulin dependent kinase in MH-susceptible vs control human samples. 4. Increased phosphorylation of additional endogenous protein components of molecular mass 116 and 60 kDa was observed.

Pathogenesis and treatment of neuroleptic malignant syndrome

1. Neuroleptic drugs (antipsychotics) produce numerous side effects which include serious extrapyramidal symptoms consisting of akathisia, dystonia, neuroleptic malignant syndrome, parkinsonian reactions such as postural abnormality, tremor, akinesia or bradykinesia, rigidity, and tardive dyskinesia. 2. Among the complications of neuroleptic chemotherapy, the most serious and potentially fatal complication is malignant syndrome, which is characterized by extreme hyperthermia, "lead pipe" skeletal muscle rigidity causing dyspnea, dysphagia, and rhabdomyolysis, autonomic instability, fluctuating consciousness, leukocytosis, and elevated creatine phosphokinase. 3. Neuroleptic malignant syndrome should be differentiated from malignant hyperthermia, lethal catatonia, and other pathological states producing some of these same symptoms. 4. In addition to neuroleptics, malignant syndrome has been caused by thymoleptics (antidepressants), metoclopramide (antiemetic), metoclopramide combined with cimetidine, tetrabenazine, overdosage of benzodiazepine, phenelzine, dothiepin and alcohol, and amphetamine. 5. Factors leading to and/or facilitating the emergence of neuroleptic malignant syndromes are reportedly organic brain syndrome, dehydration, exhaustion, external heat load, excessive sympathetic discharge, use of long acting neuroleptics, high doses of neuroleptics, rapid dose titration with neuroleptics, abrupt discontinuation of antiparkinsonism agents, and concurrent lithium therapy. 6. Although, the pathogenesis of neuroleptic malignant syndrome is not understood completely, a blockade of dopaminergic receptors in the hypothalamus, spinal cord and striatum, an alteration of dopaminergic-serotonergic transmission in the body, an enhanced synthesis and action of prostaglandin E1 and E2, and a modification of calcium-mediated signal transduction in the body have been suggested. 7. The treatment of malignant syndrome includes immediate withdrawal of neuroleptic drugs, i.v. infusion of dantrolene, and oral administration of bromocriptine; or alternatively i.v. infusion of dantrolene and the combination of levodopa-carbidopa. 8. Other measures to enhance the therapeutic effectiveness of the aforementioned regimens are to include the use of anticholinergic drugs such as benztropine to enhance the effectiveness of bromocriptine, of lorazepam if catatonic symptoms persist, or of electroconvulsive therapy (ECT) if psychotic symptoms persist. 9. These treatments, however, must be "active" rather than "passive", in order to avert fatalities and/or unfortunate sequelae from this iatrogenic and incompletely understood disease.

Erythrocyte osmotic fragility in porcine malignant hyperthermia and effects of halothane

Malignant Hyperthermia (MH) has been shown to be due to an inherited disorder in cellular membrane systems, which also seem to be affected by halothane. With the erythrocyte osmotic fragility test we tried to find out if the erythrocyte membrane can serve as a diagnostic tool in malignant hyperthermia and as a model for halothane effects on membranes. We obtained MH susceptible and MH resistant pigs and their crossbreeds. The MH susceptible pigs showed the greatest degree of haemolysis in the erythrocyte osmotic fragility test. Furthermore, halothane increased haemolysis more in the erythrocytes of MH susceptible pigs. The MH resistant pigs were only slightly affected in both and the crossbreeds showed intermediate results. The variance occurring within one halothane group could be used to add a further distinguishing characteristic apart from the discrete halothane challenge test and so enable selection within a pure halothane group.

Involvement of the 60 kDa phosphoprotein in the regulation of Ca2+ release from sarcoplasmic reticulum of normal and malignant hyperthermia susceptible pig muscles

Junctional sarcoplasmic reticulum (SR) vesicles isolated from back muscles of normal and malignant hyperthermia susceptible (MHS) pigs were phosphorylated by addition of MgATP in the presence of 5 mM Ca2+ and 1 microM calmodulin (CaM). The major site of phosphorylation was a 60 kDa protein both in normal and MHS SR. The maximal amount of phosphorylation in MHS SR (5 pmol P/mg SR) was significantly lower than that in the normal SR (12 pmol P/mg SR). The phosphorylated 60 kDa protein was spontaneously dephosphorylated both in normal and MHS SR. Ca2+ release from the passively loaded SR was induced by a Ca2+-jump, and monitored by stopped-flow fluorometry using chlorotetracycline. In the absence of preincubation with MgATP, no significant difference was found in any of the kinetic parameters of Ca2+ release between normal and MHS SR. Upon addition of 20 microM MgATP to the passively loaded SR to phosphorylate the 60 kDa protein, the initial rate of Ca2+ release in normal SR significantly decreased from 659 +/- 102 to 361 +/- 105 nmol Ca2+/mg SR per s, whereas in MHS SR the rate decreased from 749 +/- 124 to 652 +/- 179 nmol Ca2+/mg SR per s. Addition of 20 microM adenosine 5'-[beta, gamma-imido]triphosphate (p[NH]ppA) did not significantly alter the initial rate of Ca2+ release both in normal and MHS SR. These results suggest that the previously reported higher Ca2+ release rate in MHS SR (Kim et al. (1984) Biochim. Biophys. Acta 775, 320-327) is at least partly due to the reduced extent of the Ca2+/CaM-dependent phosphorylation of the 60 kDa protein. Two-dimensional gel electrophoresis study showed that amount of a protein with Mr = 55,000 was significantly lower in MHS SR than in normal SR suggesting that the abnormally lower amount of 55 kDa protein would cause the lower amount of phosphorylation of the 60 kDa protein in MHS SR.

Malignant hyperthermia in the Wolf-Hirschhorn syndrome

A case of malignant hyperthermia in a small child with a chromosomal abnormality is described. The management of malignant hyperthermia in very small children is discussed.

Malignant hyperthermia

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

Malignant hyperthermia: molecular defects in membrane permeability

Malignant hyperthermia (MH), a genetically inherited disorder of skeletal muscle, is due to molecular defect in membrane permeability. The alteration in membrane permeability is suggested to be due to enhanced phospholipase A2 activity which is responsible for the increased level in sarcoplasmic Ca2+. The excess Ca2+ is responsible for muscle hyper-rigidity and enhanced rate of glycolysis, resulting in a rapid rate of lactic acid production and a low pH in MH muscle.

Kinetic studies of Ca2+ release from sarcoplasmic reticulum of normal and malignant hyperthermia susceptible pig muscles

The time-course of Ca2+ release from sarcoplasmic reticulum isolated from muscles of normal pigs and those of pigs susceptible to malignant hyperthermia were investigated using stopped-flow spectrophotometry and arsenazo III as a Ca2+ indicator. Several methods were used to trigger Ca2+ release: (a) addition of halothane (e.g., 0.2 mM); (b) an increase of extravesicular Ca2+ concentration ([Ca2+0]); (c) a combination of (a) and (b), and (d) replacement of ions (potassium gluconate with choline chloride) to produce membrane depolarization. The initial rates of Ca2+ release induced by either halothane or Ca2+ alone, or both, are at least 70% higher in malignant hyperthermic sarcoplasmic reticulum than in normal. The amount of Ca2+ released by halothane at low [Ca2+0] in malignant hyperthermic sarcoplasmic reticulum is about twice as large as in normal sarcoplasmic reticulum. Membrane depolarization led to biphasic Ca2+ release in both malignant hyperthermic and normal sarcoplasmic reticulum, the rate constant of the rapid phase of Ca2+ release induced by membrane depolarization being significantly higher in malignant hyperthermic sarcoplasmic reticulum (k = 83 s-1) than in normal (k = 37 s-1). Thus, all types of Ca2+ release investigated (a, b, c and d) have higher rates in malignant hyperthermic sarcoplasmic reticulum than normal sarcoplasmic reticulum. These results suggest that the putative Ca2+ release channels located in the sarcoplasmic reticulum are altered in malignant hyperthermic sarcoplasmic reticulum.

In vivo induced malignant hyperthermia in pigs. III. Localization of calcium in skeletal muscle mitochondria by means of electronmicroscopy and microprobe analysis

Biceps femoris muscle biopsies of malignant hyperthermia susceptible (MH+) and non-susceptible (MH-) Dutch Landrace pigs were studied ultrastructurally, and exchangeable calcium was demonstrated, using the antimonate precipitation technique in combination with electron probe x-ray microanalysis. Biopsies were taken before and during the administration of halothane-plus-succinylcholine and after dantrolene sodium treatment of the animals. MH+ muscle, taken before the MH triggering, showed a high proportion (about 35%) of cells with supercontraction. Both MH+ and MH- muscle had broad but nearly identical ranges of cell diameter. Core-like structures were occasionally present in muscle from MH+ pigs. Muscle mitochondria from the MH+ pigs accumulated large amounts of calcium in their matrix compartment during the halothane-plus-succinylcholine induced MH crisis. This calcium loading in the course of time caused swelling and structural damage to the mitochondria. Skeletal muscle mitochondria from MH- pigs did not show such a reaction pattern on challenge with halothane and succinylcholine. It is concluded that in MH+ pigs the challenge brings about an increase in myoplasmic free calcium, which is predominantly due to calcium influx from the extracellular fluid. This rise in cytosolic calcium causes the mitochondria to accumulate the cation in an energy-dependent way. These findings are discussed in relation to the diverging halothane and caffeine contraction responses of aerobic type I and anaerobic type II muscle fibres.

Malignant hyperthermia in a myopathic child. Prolonged postoperative course requiring dantrolene

An 18-month-old boy with congenital muscular dystrophy began to develop clear signs of the malignant hyperthermia syndrome after 85 min of halothane/nitrous oxide anaesthesia. Dantrolene, 2 mg/kg i.v., was immediately effective, but temperature, heart rate and carbon dioxide production were all increased for 2 days postoperatively in spite of repeated dantrolene administration.

Use of a designed experiment for the study of muscle fibre size

Malignant Hyperpyrexia (MH) is the manifestation of an underlying muscle disease. In routine clinical examination of muscle biopsy tissue it had been noted that muscle fibre sizes appeared to differ between MH-susceptible individuals and non-susceptible individuals. A designed experiment was required to utilize data from the muscle samples at hand and to form the basis for a more general investigative study. The experiment and ensuing analysis are described and the results and their implications are discussed.

The genetics of malignant hyperthermia: evidence for heterogeneity

Study of phenotype and familial distribution of malignant hyperthermia (MH) suggests heterogeneity with MH possibly being a symptom of several disorders. Review of all reported family studies supports the concept of heterogeneity with autosomal dominant inheritance in about one-half of the families. There is no strong evidence for other mendelian patterns of inheritance, but sporadic and possibly multifactorially determined cases are common. MH is also seen in other musculoskeletal disorders. We report 12 Wisconsin families with MH and outline a preliminary approach to the counseling of MH patients and their families.

Management of a malignant hyperthermia patient during cardiopulmonary bypass

The anaesthetic management of cardiopulmonary bypass (CPB) for a patient with biopsy-proven malignant hyperthermia is reported. Specific changes in the technique used, such as venting the oxygenator before use, monitoring mixed venous PO2 and PCO2, as well as the safety of cold hyperkalaemic cardioplegia are described. Controversial aspects of malignant hyperthermia management such as the safety of calcium and catechol inotropes are discussed in relationship to the successful use of cardio-pulmonary bypass in our patient. We chose to treat left ventricular dysfunction by aggressive vasodilator (nitroglycerine) therapy. We detected no myocardial or respiratory depression secondary to dantrolene therapy either before or after operation.

High skeletal muscle adenylate cyclase in malignant hyperthermia

Malignant hyperthermia occurs in humans with several congenital myopathies, usually in response to general anesthesia. Commonly, individuals who develop this syndrome lack symptoms of muscle disease, and their muscle lacks specific pathological changes. A biochemical marker for this myopathy has not previously been available; we found activity of adenylate cyclase and content of cyclic AMP to be abnormally high in skeletal muscle. Secondary modification of protein phosphorylation could explain observed abnormalities of phosphorylase activation and sarcoplasmic reticulum function.

Malignant hyperpyrexia: successful management following oral surgery

Malignant hyperpyrexia (M.H.) is a rare, important and frequently fatal disease provoked by inhalational anaesthetic agents and other drugs. It is manifested most frequently by tachycardia, a rise in core body temperature, muscle stiffness and is associated with profound metabolic effects. It may be transmitted in a predictable familial dominant fashion, but sporadic cases in whom this transference cannot be demonstrated do occur. Susceptibility may be revealed on questioning regarding previous anaesthetic exposure. One such unexpected but successfsully treated case of M.H. is described in detail and the current management and investigation is discussed.

Plasma cholinesterase variants and the anaesthetist

Biochemical properties of plasma cholinesterase of significance to the anaesthetist are reviewed. The role of the genetic variants of the enzyme in suxamethonium sensitivity and hyperthermia are discussed with emphasis on the pregnant patient. Altered gene frequencies of the enzyme variants in some mental disorders is commented upon.

The histology of myocardium in malignant hyperthermia: a preliminary report of 11 cases

The preliminary results of a retrospective examination of the myocardium from 11 patients who responded to general anaesthesia with malignant hyperthermia are presented. Light-microscopical examination of the sections revealed no specific changes due to malignant hyperthermia. Contraction bands were demonstrated in 4 cases and it is concluded that the present investigation does not support the suggestion that a specific myofibrillar damage is responsbile for the arrhythmias seen in malignant hyperthermia.

Malignant hyperthermia

A case has been presented that illustrates successful managment of a patient with suspected malignant hyperthermia. The causes of this disorder are uncertain. If screening procedures identify a patient as susceptible to this disorder, careful planning in the preoperative stage is indicated. Preparedness during the operative procedure for any emergency is mandatory. Early and effective treatment seems to be the only method of preventing mortality with patients experiencing malignant hyperthermia.

Malignant hyperthermia. Report of two cases

A dentist using local or general anesthetics must be cognizant of the possibility of malignant hyperthermia presenting as a catastrophic emergency. The purpose of this article is to describe the syndrome of malignant hyperthermia, to emphasize its early clinical symptoms, and to outline definitive treatment. Two cases of malignant hyperthermia in pediatric dental patients illustrate the clinical and laboratory features and the appropriate therapy.

[A case of malignant hyperthermia occuring in a dental clinic]

Malignant hyperthermia, a life-threatening complication of anaesthesia, occurred in a 5 1/2-year-old girl undergoing dental surgery in a dental clinic. During induction, after 20 mg of succinylcholine, the anaesthetist noted a moderate rigidity of the mandible that did not interfere with the tracheal intubation. However, after 45 minutes, the temperature rose to 38.8 degrees C, pulse was rapid at 160 per minute and the child was slightly cyanosed. The diagnosis of malignant hyperthermia was made (the temperature eventually reached 40.8 degrees C). The child was immediately treated with refrigeration, procainamide and sodium bicarbonate. She was then moved to a hospital centre where the treatment was continued and she recovered completely. After extensive investigation, we found that the paternal grandfather of the child died at age 58, several hours after a bilateral lumbar sympathectomy under general anaesthesia. The cause of the death, as confirmed by hospital records, was malignant hyperthermia. No genetic counselling was given at that time; this omission has since been corrected. Early diagnosis and the availability on the premises of the necessary drugs and equipment to treat such a complication probably saved this child's life. In 1975, "La Corporation Professionnelle des Médecins du Québec" published standards for practice of anaesthesia outside a hospital setting. The compliance of the dental clinic with such standards has contributed to the avoidance of a catastrophe.

Cardiac manifestations of malignant hyperthermia susceptibility

Malignant hyperthermia is a disease resulting from defective cellular membranes, usually presenting as drug-induced pyrexic crises. We describe four patients with life threatening ventricular arrhythmias or chest pain in the absence of pyrexic crises. Three presented with life threatening arrhythmias and the fourth with severe atypical chest pain. Two patients had a family history of multiple sudden deaths. Resting CKs were elevated in three patients while CK-MB was elevated in one. Resting ECGs were abnormal in three. Three patients had recurrent ventricular tachycardia, two had recurrent ventricular fibrillation and multiple cardiac arrests. Cardiac catheterization showed abnormal left ventricular wall motion in two and minimal mitral valve prolapse in one while all had normal coronary arteries. Thallium-201 myocardial imaging demonstrated large perfusion defects in the patient with electrocardiographic Q waves and normal coronary arteries. Myocardial involvement has been demonstrated by clinical, electrocardiographic, hemodynamic, angiographic and myocardial imaging abnormalities. Malignant arrhythmias occurred in these patients in the absence of pyrexic crises or drug admininstration. Abnormal calcium release in the myocardium, as documented in skeletal muscle membranes, may be a unifying concept for the various manifestations described.

Preoperative and operative considerations in malignant hyperpyrexia

Malignant hyperpyrexia is a condition characterized by fever and often by skeletal muscle rigidity usually triggered by the administration of general anesthetic agents. A review of the current literature is given to emphasize preoperative and operative considerations. An uncomplicated case is presented to illustrate the special care that these individuals require.

Malignant hyperthermia: a complication of orthopedic surgery

Although malignant hyperthermia is seen most frequently as a complication of orthopedic surgery, most orthopedists have not encountered this commonly fatal problem. A case report and discussion of the inheritable metabolic defect is given. Immediate treatment concepts are discussed.

Myoglobin: methods and diagnostic uses

Myoglobin is the oxygen-binding protein characteristic of skeletal and cardiac muscle. With muscle disease or dysfunction, myoglobin may enter the circulation, and after renal clearance, it may also appear in the urine. Therefore, the presence of myoglobinemia and myoglobinuria may serve as indicators of the presence and severity of muscle disease. With newly developed methods of detection, myoglobinemia and myoglobinuria are now recognized as complications of trauma, ischemia, surgery, states of exertion and stress, metabolic abnormalities, inherited enzyme disorders, toxin and drug actions, and inflammatory states. Infarction of the heart muscle also can be detected by myoglobin assay. Persistent myoglobinuric states may be complicated by renal failure and electrolyte imbalance. The diagnosis of myoglobinemia and myoglobinuria can be now confirmed with the use of immunoassay techniques. Although not yet widely available, they offer the possibility of the specificity and sensitivity needed for clinical use.