Dr Abdullah Ansari
PG-2 (Medicine)
AMU ALIGARH
A general approach to periodic paralysis....
(including hypokalemic periodic paralysis and thyrotoxic periodic paralysis, and other “Channelopathies” or “Membranopathies)
Pathophysiology
Epidemiology
Primary or familial periodic paralysis
Secondary periodic paralysis
Conventional classification of periodic paralysis
Classification of primary periodic paralysis based on ion-channel abnormalities
Clinical approach to a case of periodic paralysis
History of muscle weakness
Age of onset
Family history
Timing
Intensity
History of administration of certain drugs
Clinical examination
Differential Diagnosis
Laboratory investigations
Serum K+
CPK and serum myoglobin
ECG
EMG
Nerve conduction studies
Provocative Testing
Muscle biopsy
Treatment
Prognosis
This presentation consist information about unspoken and less well known variants of GBS as well as CIDP. Also it includes information about diagnosis and management.
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Ion channels, types and their importace in managment of diseasesFarazaJaved
This topic covers voltage gated type of ion channel, general structure and functioning of ion channels and involvement of different ion channel types in the pathogenesis as wella as a target for the development of various diseases.
Dr Abdullah Ansari
PG-2 (Medicine)
AMU ALIGARH
A general approach to periodic paralysis....
(including hypokalemic periodic paralysis and thyrotoxic periodic paralysis, and other “Channelopathies” or “Membranopathies)
Pathophysiology
Epidemiology
Primary or familial periodic paralysis
Secondary periodic paralysis
Conventional classification of periodic paralysis
Classification of primary periodic paralysis based on ion-channel abnormalities
Clinical approach to a case of periodic paralysis
History of muscle weakness
Age of onset
Family history
Timing
Intensity
History of administration of certain drugs
Clinical examination
Differential Diagnosis
Laboratory investigations
Serum K+
CPK and serum myoglobin
ECG
EMG
Nerve conduction studies
Provocative Testing
Muscle biopsy
Treatment
Prognosis
This presentation consist information about unspoken and less well known variants of GBS as well as CIDP. Also it includes information about diagnosis and management.
This is a brief review of autoimmune epilepsies, especially autoimmune encephalitis, SREAT, NORSE, FIRES and Rasmussen's encephalitis. A brief overview of investigations and treatment is included.
Ion channels, types and their importace in managment of diseasesFarazaJaved
This topic covers voltage gated type of ion channel, general structure and functioning of ion channels and involvement of different ion channel types in the pathogenesis as wella as a target for the development of various diseases.
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The generation of an action potential in heart muscle
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The patch-clamp technique enables the investigation of
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The Isolated cells are ready for experiment.
Glass micro-pipette - a tip opening of about 1 μm, is
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5. Voltage-Gated Ion Channels
• The voltage sensor is a region of the protein bearing charged
amino acids that relocate upon changes in the membrane
electric field.
Segments (S5 and S6) and the pore loop
were found to be responsible for ion conduction.
Lipid bilayer
Transmembrane
segment (cylinder)
Voltage sensor Pore
part of the channel
General architecture of voltage-gated channels (Na+ and Ca2+).The “+” or “-“ signs
indicate charges that have been implicated in voltage sensing.
6. Each alpha1subunit has 4 homologous repeat domains, each comprised of
6 transmembrane segments alpha1 modulated by other subunits
7. Figure 3.Structure of Ion Channels.
Panel A shows a subunit containing six transmembrane-spanning motifs, S1
through S6, that forms the core structure of sodium, calcium, and potassium
channels.
.
Panel B shows four such subunits assembled to form a potassium channel.
12/12/2012
19. HYPOKALEMIC PERIODIC PARALYSIS
MUTATED GENE CALCL1A3 SCN4A
CHROMOSOME 1q31 17q
DEFECTIVE CALCIUM SODIUM
CHANNEL
MODE OF AUTOSOMAL DOMINANT
INHERITENCE
TYPE 1 TYPE 2
20. Hypokalemic Periodic Paralysis
Pathophysiology
• The mutation slows the activation rate of L-type Ca
current to 30% of NormaL
• Reduced RYR1-mediated Ca release from SER
• Reduced calcium current density
• Impaired E-C coupling
• Ca homeostasis change reduces ATP-dependent K
channel current and leads to abnormal depolarization
(Tricarico D et al 1999)
20
21. HYPOKALEMIC PERIODIC PARALYSIS
PREVELANCE 1:100,000
AGE OF ONSET FIRST AND SECOND DECADE OF
LIFE
SYMPTOMS DURING ATTACKS ACUTE ONSELT FLACCID
PARALYSIS
PROXIMAL >>> DISTAL
SYMPTOMS BETWEEN ATTACKS REGAIN FULL STRENGTH
BETWEEN ATTACKS
TRIGGERS HIGH CARBOHYDRATE,HIGH
SALT,
DRUGS- BETA AGONISTS,
INSULIN
REST FOLLOWING PROLONGED
EXERCISE
22. SERUM POTASSIUM LOW
CONCENTRATION
ECG HYPOKALEMIC CHANGES
MUSCLE BIOPSY SINGLE OR MULTIPLE
CENTRALLY PLACED
VACUOLES
NERVE CONDUCTION TEST REDUCED AMPLITUDE OF
ACTION POTENTIAL
ELECTROMYGRAPHY ELECTRICALLY SILENT
GENETIC STUDY CALCL1A3, SCN4A
23. TREATMENT ORAL KCL
SUPPLEMENTATION
KCL VIA INFUSION
DONOT GIVE IN DEXTROSE
PROPHYLAXIS ACETAZOLAMIDE
(125-1000 Mg)
PROGNOSIS USUALLY GOOD
RARE DEVELOPMENT OF
PROXIMAL MYOPATHY
*Never forget to measure the thyroid hormones.
24. • The mechanism of effect of acetazolamide is not discovered.
Acetazolamide produced a mild metabolic acidosis but did not
have a demonstrable effect on total body sodium, total body
potassium, or thyroid function.
• Acetazolamide is the most effective treatment available for
hypokalemic periodic paralysis.
26. Pathophysiology
In hyperKPP, Na+ channels fail to inactivate and
prolonged openings and depolarization result.
The result is that persistent Na+ currents are
witnessed, the Na+ current is closer to the
maximum, and Na+ diffuses down its gradient into
the cell which results in a depolarization and a more
positive membrane potential.
Increased extracellular K+ levels worsen the
inactivation
27. HYPOKALEMIC HYPERKALEMIC
PREVELANCE 1:100,000 1:200,000
AGE OF ONSET FIRST AND SECOND FIRST DECADE
DECADE OF LIFE
SYMPTOMS DURING ACUTE ONSELT FLACCID WEAKNESS OF
ATTACKS PARALYSIS PROXIMAL
PROXIMAL >>> DISTAL MUSCLE,SPARING
BULBAR MUSCLE
SYMPTOMS BETWEEN ASYMPTOMATIC ASYMPTOMATIC
ATTACKS
TRIGGERS HIGH CARBOHYDRATE, REST AFTER EXERCISE
HIGH SALT, STRESS
DRUGS-BETA FATIGUE
AGONISTS, INSULIN FOOD HIGH IN
REST FOLLOWING POTASSIUM
PROLONGED EXERCISE
POSTASSIUM TREATMENT PROVOCATIVE TEST
SUPPLEMENTATION
28. SERUM LOW HIGH, NORMAL
POTASSIUM
CONCENTRATION
ECG HYPOKALEMIC HYPERKALEMIC CHANGES
CHANGES CHANGES
MUSCLE BIOPSY SINGLE OR MULTIPLE SMALLER, LESS
CENTRALLY PLACED NUMEROUS
PERIPHERALLY PLACED
VACUOLES VACUOLES
NERVE CONDUCTION TEST REDUCED REDUCED AMPLITUDE OF
AMPLITUDE OF ACTION POTENTIAL
ACTION POTENTIAL
ELECTROMYGRAPHY ELECTRICALLY SILENT ELECTRICALLY SILENT
MYOTONIC DISCHARGE
BETWEEN ATTACKS
GENETIC STUDY CALCL1A3, SCN4A SCN4A
30. • Abstract
We studied the effect of acetazolamide on plasma potassium
in normals and in two patients with hyperkalemic periodic
paralysis.
Administration of acetazolamide for 48 hours lowered mean
plasma potassium in normals from 4.01 to 3.56 mEq per liter
(p less than 0.001) and in the patients from 4.55 to 4.00 mEq
per liter (p less than 0.001).
This kaliopenic effect of acetazolamide may account for its
therapeutic action in hyperkalemic periodic paralysis.
37. Figure 1. Andersen's Syndrome Is Characterized by Dysmorphic Features, Cardiac Arrhythmias,
and Periodic Paralysis(A and B) Andersen's patient exhibiting low set ears, hypertelorism,
micrognathia, and (C) clinodactyly of the fifth digits. (D) ECG rhythm strip from an Andersen's
patient demonstrating short runs of polymorphic ventricular tachycardia. (E) Muscle biopsy of an
Andersen's patient exhibiting tubular aggregates commonly seen in periodic paralysis patients
43. Malignant hyperthermia
Skeletal muscle Rigidity and weakness
Rhabdomyolysis
Muscle spasms especially affecting
masseter, but can
be generalised
Myalgia
Autonomic Sympathetic overactivity
Hyperventilation
Tachycardia
Haemodynamic instability
Cardiac arrhythmia
Laboratory Increased oxygen consumption
Hypercapnia
Lactic acidosis
Raised creatine kinase
Hyperkalaemia
44. Malignant hyperthermia
Full episodes: general anaesthesia (inhalational
Triggers agents— isoflurane, desflurane,) suxamethonium
Milder malignant hyperthermia: exercise in hot
conditions, neuroleptic drugs, alcohol, infections
Dantrolene 2 mg/kg intravenously every 5 minutes to
Treatment a total of 10 mg/kg
Hyperventilation with supplemental oxygen
Sodium bicarbonate
Active cooling
Discontinue anaesthesia
Maintain urine output over 2 ml/kg/hour
Avoid calcium, calcium antagonists, b-blockers
45. THE CONGENITAL MYASTHENIC
SYNDROMES
• GENETIC MUTATION IN ANY COMPONENT OF
NEUROMUSCULAR JUNCTION
Type Genetics
Slow channel Autosomal dominant; AChR mutations
Low-affinity fast channel Autosomal recessive; may be
heteroallelic
Severe AChR deficiencies Autosomal recessive; mutations most
common; many different mutations
AChE deficiency Mutant gene for AChE's collagen
anchor
46. • SYMPTOMS BEGAIN IN INFANCY
• AChR TEST IS PERSITANTLY NEGATIVE
• TREATMENT
PYRIDOSTGMINE
3,4 DIAMINOPYRINE
51. BURGADA SYNDROME
DIMINISHED SODIUM INWARD CURRENT AT REGION
OF RIGHT VENTICULAR OUT FLOW
RAPID DEPOLARIZATION OF THAT AREA
TRANSIENT OR CONCEALED ST ELEVATION V1-V3
PROVOKED WITH NA+ CHANNEL BLOCKING DRUGS
RISK OF POLYMORPHIC VENTICULAR
TACHYCARDIA
54. FAMILIAL HEMIPLEGIC MIGRANE
• AUTOSOMAL DOMINANT
• TYPE 1-3
• GENE MUTATED-CACNA1A,ATP1A2,SCN1A
• ION CHANNEL-VOLTAGE DEPENDENT P/Q TYPE
CALCIUM CHANNEL
55. • DIAGNOSTIC CRITERIA
• AT LEAST TWO ATTACKS OF MIGRANE WITH
AURA
• AURA MUST INCLUDE REVERSIBLE MOTOR
DEFICIT
• POSITIVE FAMILIT HISTORY
• TREATMENT- ACETAZOLAMIDE VERAPAMIL
60. Summary.
Channel mutations are an increasingly
recognized cause of disease.
Many channelopathies episodic despite
persistently abnormal channel.
Triggers recognized for some diseases.
Abnormalities in same channel may present with
different disease states
Lesions in different channels may lead to same
disease eg periodic paralysis
Disease mechanism often unclear despite
identification of mutation.
61. REFRENCES
• Harrison’s principles of internal medicine18th ed
• T d graves, m g hanna, neurological channelopathies,
postgrad med j 2005;81:20–32. Doi: 10.1136/pgmj.
2004.022012
• Bernard and shevell; channelopathies, pediatrneurol.
2007. 09.007
• Mechanisms and clinical management of inherited
channelopathies: long qt syndrome, brugada syndrome,
catecholaminergic polymorphic ventricular tachycardia, and
short qt syndrome; elizabeth s. Kaufman, md, heart rhythm
society, doi:10.1016/j.Hrthm.2009.02.009
• Guyton and hall textbook of medical physiology (12th edn)
Now we know that there is a mutation in the skeletal muscle ca channel which slows the rate of channel activation and therefore ca influx. As mentioned earlier this receptor also acts as a voltage sensor leading to reduced ryanodine receptor medicated ca release from the SER leading to reduced calcium current leading to impaired E-C coupling. The exact role of hypokalemia is not well understood. As with other forms of paralysis, muscle fibres are depolarized and inexcitable during the attack. In vitro, muscle fibres from pts with hypoKPP exposed to low K shows paradoxical depolarization. Hence hypothesizing that cal channel mutation leads to changes in calcium homeostasis which reduces ATP dependent K current creating a hypokalemic state which leads to abnormal depolarization.One of the theoriesα subunit of the voltage-gated calcium channel, Cav1.1 (also known as the skeletal muscle L-type calcium channel, and the dihydropyridine receptor HypoPP is most commonly associated with mutation of CACNA1S (type I HypoPP), which encodes the α subunit of the voltage-gated calcium channel, Cav1.1 (also known as the skeletal muscle L-type calcium channel, and the dihydropyridine receptor). Cav1.1 in the T-tubular membraneis attached to the ryanodine receptor of sarcoplasmic reticulum, for which it acts as a voltage sensor. About 10% of HypoPP is associated with mutations in SCN4A (type 2 HypoPP), which encodes the skeletal muscle sodium channel.