2. What is congenital myasthenic
syndrome??
Inherited disorder of neuromuscular transmission associated with
abnormal weakness and fatiguability on exertion.
The prevalence of CMS is estimated at one in 500 000 in Europe, and CMSs
are much more uncommon than autoimmune myasthenia
Acetylcholinesterase deficiency was the first CMS identified, based on
the lack of the enzyme at neuromuscular junctions
In the experience of Engel’s group, postsynaptic CMSs are three times
more frequent than acetylcholinesterase deficiency and 10 times more
frequent than presynaptic
3. Is CMS the same as myasthenia gravis?
No.
An autoimmune condition like rheumatoid arthritis,
which can affect both children and adults.
Myasthenia gravis causes the body to produce proteins
that block and destroy some of their receptors, making
messaging from nerves to muscles less effective.
Myasthenia gravis can be treated with steroids,
immunosuppressive drugs and thymectomy (surgical
removal of the thymus gland).
7. Transmitter quantum
Amount of Ach released from single synaptic vesicles.
Electrophysiologically measurable parameters of
quantal release –
mnp
mnumber of quantum realeased
n number of readily releasable quanta
p probablity of release
10. Ca2+
Ca2+
channel
↑Ca2+ calcium calmodulin protein kinase phosphorylates
synapsin releases Ach from synaptic vesicles by exocytosis
ACh
Presynaptic
terminal
15. Structure of AchE
Acetylcholinesterase (AchE) is an
enzyme, which hydrolyses the
neurotransmitter acetylcholine.
The active site of AChE is made up of
two subsites, both of which are critical to
the breakdown of ACh.
The anionic site serves to bind a molecule
of ACh to the enzyme. Once the ACh is
bound, the hydrolytic reaction occurs at a
second region of the active site called the
esteratic subsite.
Here, the ester bond of ACh is broken,
releasing acetate and choline. Choline is
then immediately taken up again by the
high affinity choline uptake system on the
presynaptic membrane.
15
16. MEPP , MEPC & EPP
Single quantum Deporalization and current flow MEPP
and MEPC
MEPP Number and conductance per channel opened,
resistance of muscle fibre and functional state of AchE
MEPC number of channel opening and the current per
channel flowing
EPP nonlinear summation of individual quanta produces a
large deporalization which is EPP.
17. SAFETY MARGIN OF NM
TRANSMISSION
Difference between the depolarization caused by EPP
and depolarization required to activate the Na
Channel.
All congenital or acquired cause of neuromuscular
transmission have been shown to sub threshold EPP
for activating Na or Na channel unresponsiveness to
EPP
18. Saturating disc model of NM
transmission
MEPPs are believed to be the depolarization of the muscle membrane caused by
the action of the acetylcholine released by a single synaptic vesicle which
spontaneously fused with the presynaptic membrane – this is the vesicle
hypothesis
Quantal nature of the small EPPs
Fusion of no vesicles = no EPP
Fusion of one vesicle = MEPP (0.5mV)
Fusion of three vesicles = EPP with an amplitude 3x the MEPP (1.5mV)
10-20% of 10,000 molecules of ACh released by a single vesicle bind to AChE in the
cleft
the remaining NT binds to AChR in a patch of about 0.3m m2 in area = the disk of
AChR saturated with agonist NT
Saturated disk model: vesicle releases enough ACh to bind all AChE and AChR in 0.1
ms
19. Congenital Myasthenic Syndromes
Congenital Myasthenic Syndromes are inherited
disorders of neuromuscular transmission.
CMS was recognized 1st time in late 1970’s and early
1980’s after recognization of auto immune origin of
myasthenia gravis
During the past decade various divergent types of CMS
were identified
Various classifications were done but Mayo clinic and
European neuromuscular centre classification was
mostly accepted
20.
21. Frequencies of identified mutations
Mutations in AChR subunits,
55%
Low-expressor in e subunit,
34%
Low expressor in other AChR
subunits, 3%
Slow channel mutations, 12%
Fast channel mutations, 6%
Rapsyn, 15%
ColQ, 15%
Dok-7, 9%
ChAT, 6%
Nav1.4, Plectin, Agrin, MuSK,
Laminin b2 <1%
If clinical data provides no
clues for targeted mutation
analysis, search for mutations
in descending order as listed
Screen for common mutations
in RAPSN and DOK7
Search for common mutations
in ethnic groups (e.g,
e1267delG)
22. Diagnostic Clues in CMS
Weakness/fatigability of limbs and oculobulbar
muscles
Early onset (since neonatal period)
Positive family history
EDX findings (RNS, SFEMG)
Response to anti-cholinesterases
Absence of anti-AChR, MuSK , VGCC antibodies
23. Diagnostic Difficulties
Diagnostic problems
Late onset (in adult)
No response to anticholinesterases
No family history
Episodic symptoms
No ophthalmoplegia or cranial involvement
Decrement may not be present in all muscles, or
present only intermittently
Misdiagnosed as
congenital myopathy
Seronegative MG (late onset)
Metabolic myopathies
24. Investigations of Endplate Diseases
Clinical
- History, examination, response to Tensilon or 3,4-DAP
- EMG: repetitive nerve stimulation, SFEMG
- Serologic tests: AChR and MuSK antibodies, tests for
botulism
Muscle biopsy studies: morphology
- Cytochemical localization of AChR, AChE, immune deposits
- AChR per endplate (125I-a-bungarotoxin)
- Quantitative EM, immuno-EM
Muscle biopsy studies: electrophysiology
- Microelectrode studies: MEPP, MEPC, EPP, m, n, p
- Single-channel patch-clamp recordings
Mutation analysis and expression studies
26. Presynaptic Syndromes
Choline Acetyltransferase Deficiency
Paucity of synaptic vesicles and reduced quantal
release
Lambert-Eaton-Like syndrome
Other syndromes associated with reduced quantal
release
27. Choline Acetyltransferase
Deficiency
Recognized 3 decades ago
Previously it was called as Familial Infantile
Myasthenia
Distinguishing features are sudden and expected
dyspnea and bulbar weakness CMS with episodic
apnea (CMS-EA)
Impaired vesicular packaging and resynthesis of Ach.
28. Choline Acetyltransferase
Deficiency
Clinical Features
Most cases in infancy
Sudden unexpected episodes of dyspnea and bulbar
weakness culminating in apnea (CMS-EA)
Some patients had hypotonia, bulbar and respiratory
weakness at birth requiring ventilator
29. Others develop symptoms during childhood
precipitated by cold or infection.
After age of 10 symptoms less severe and there is
no loss of muscle bulk nor permanent myopathy
Phenotypic heterogenity may be seen in
kinships.
With increase in age exacerbation are less severe.
31. Choline Acetyltransferase
Deficiency
Electrophysiology
1. Decremental response seen in weak muscles.
2. SFEMG similar to MG
3. Weakness induced by exercise and RNS at 10 Hz.
4. Decrement can be corrected by edrophinium.
End plate studies
1. Number of AChRs/end plate and postsynaptic structure
normal
2. Synaptic vesicles smaller in rested muscle
3. MEPP and EPP normal at rest but decreases with 10 Hz
stimulation with slow recovery over 10 to 15 mins.
32. Molecular study….
Impaired vesicular packaging and Ach resynthesis
4 genes impicated:
1. Presynaptic high affinity choline transporter
2. CHAT
3. VAchT
4. Vesicular proton pump
5. Patients had no ANS and CNS involvement
suggested that selectively vulnerable to CHAT.
34. Paucity of synaptic vesicles and reduced
quantal release
Only 1 patient reported till date
Clinical and EMG finding similar to auto immune MG
But onset was at birth, Anti- AChR antibodies
absent, no endplate AChR deficiency
EM Revealed No Post synaptic abnormality
35. Paucity of synaptic vesicles and reduced
quantal release
Decreased (20%) ACh Quanta (m) release by nerve
impulse due to decreased number of readily releasable
qaunta (n).
Decreased density of synaptic vesicles by about 20% of
normal in unstimulated nerve terminals
Patients symptom improved by pyrodistigmine.
36. Paucity of synaptic vesicles and reduced
quantal release
Disorder stems from paucity of synaptic vesicles.
Synaptic vessel protein in perikaryon of Ant horn cell
carried distally by kinesin assembled in nerve terminal
Packed to form Ach.
Basic defects maybe due to-
1. Defect in formation of synaptic vesicles precursors in anterior
horn cells
2. Defect in axonal transport
3. Impaired assembly of mature vesicles
4. Impaired recycling
38. Lambert-Eaton-Like syndrome
At Mayo clinic, a 6 months old girl presented with
severe bulbar and limb weakness, hypotonia, areflexia
and respirator dependency since birth.
EMG showed low amplitude CMAP which facilitated
500% on high frequency stimulation and 40%
decrement on low frequency.
Amplitude of CMAP was abnormally small but
facilated several fold on tetanic stimulation.
39. Lambert-Eaton-Like syndrome
EM revealed no defect in pre or post synaptic regions.
AChR and synaptic vesicles were normal.
MEPP amplitude was normal for muscle fiber size
Quantal content of EPP at 1 Hz stimulation was less
than 10% and at 40Hz increased by 300%
40. Lambert-Eaton-Like syndrome
EMG abnormality improved by 3,4-DAP but patient
remained weak.
Molecular basis- ? presynaptic voltage gated calcium
channel or ? Vesicular release complex defect.
Mutation analysis of CACNA1A gene revealed no
abnormality.
41. Other syndromes associated with reduced
quantal release
Maselli et al reported 3 sporadic patients, 1 more than
5 years and 2 in early infancy.
They had truncal or limb ataxia and 1 had horizontal
nystagmus with sparing of external occular muscles.
EMG- decremental response at 2 Hz which did not
improve with high frequency
No AChR deficiency
42. Other syndromes associated with reduced
quantal release
EM-normal nerve terminal, normal no. of synaptic vesicles
with small double membrane
In vitro microelectrode- decrease in no. of quanta released
at 1 Hz
No mutation detected
One patient responded to pyridostigmine and 3,4-DAP and
another mild response to pyridostigmine and ephedrine.
45. Congenital End plate Acetylcholinesterase
deficiency
Myasthenia refractory to AChE inhibitors.
AChe was absent from endplate detected by
cytochemical and immunocytochemcal criteria.
46. Clinical Features
Symptoms since birth (poor suck, cry, dyspnea)
Delayed motor milestones
Weakness of facial, cervical, axial and limb muscles
Ophthalmoparesis in some pts with abnormally slow pupillary
reactions.
Fixed scoliosis, severe weakness & atrophy of dorsal forearm &
intrinsic muscles of hand.
Patients presenting in childhood become disabled only in 2nd
decade while in some others with severe symptoms at birth
had improved during adolescence.
47. •11 yo, weak since infancy with ptosis, restricted EOM, sluggish
pupillary reflex, lordosis
•Worsening with Mestinon, some response to pseudo-ephedrine
49. Congenital End plate Acetylcholinesterase
deficiency
Electrophysiology
1. Decremental response at 2 Hz
2. Nerve stimulation evokes a repititive CMAP which is because of prolonged
lifetime of acetyl choline.
3. In vitro microelectrode- MEPP normal or reduced, decay time prolonged
(MEPP & MEPC), no response to prostigmine.
4. Quantal content(m) is decreased which is because of decrease in readily
releasable quanta (n).
5. Kinetic property of AchR are normal by patch clamp analysis.
51. Congenital End plate Acetylcholinesterase
deficiency
Morphologic Features
1. AChE absent
2. Small and Decreased nerve terminal size and presynaptic
membrane length. Schwann cell extend in synaptic cleft
and presynaptic membrane reduce availability of Ach
release. This decrease the quantal content.
3. Sometimes Junctional fold are degenerated with
shedding of AchR.
4. Total no. of AChR/ endplate is normal to reduced.
52. Congenital End plate Acetylcholinesterase
deficiency
Pathogenesis
Degeneration of presynaptic membrane reduction in
quantal release AChe reduced Increased lifetime of
Ach Causes cationic overloading and destruction Of
junctional fold with shedding of AchR.
Prolonged deporalization at end plate blocks Na channel
and inhibits generation of AP.
54. Congenital End plate Acetylcholinesterase
deficiency
Molecular studies
AchE is asymmetrical enzyme composed of catalytic
subunit attached to collagenic tail.
Collagenic tail is formed by ColQ.
ColQ contains PRAD (proline rich attachment
domain) associates AchE tetramer.
AchE is anchoraged to synaptic space by two
cationic heparan sulfate binding domains.
Tail subunit is anchored by heparan proteoglcan and
extracellar domain of Musk.
55. Congenital End plate Acetylcholinesterase
deficiency
AchE deficiency may occur
1. Defect in ColQ
2. Basal lamina binding partners
3. Defect in transport of assembled asymmetrical
enzyme
56. 1. Four major ColQ mutations are:
Mutation that Involve PRAD prevent attachment of AchE to
ColQ
Mutation that truncate collagen domain that prevent triple
helical association.
Carboxyl terminal mutant produces incompetent enzyme
Other C terminal mutation that produces reduced amount of
enzyme.
57. Congenital End plate Acetylcholinesterase
deficiency
Therapy
1. AChE medication should be avoided enhances
muscarinic side effects.
2. ? Ephedrine, ?prednisone
3. Atracurium is AchR blocker that prevents
overexposure of Ach.
59. Ligand- Gated Ion Channel
2α + β + ε + δ
Ach binding site is at α to ε and α to δ
Over view of AChR structure
α
60. Each subunits has
1. N terminal domain that occupy about 50 % of
primary sequence
2. 4 transmembarne domain (TMD 1-4)
3. Large cytoplasmic domain between TMD3 and TMD
4
4. Small C extracellular domain.
Ach binding sites are formed between interface
between subunits. This interface are called loops.
61. Seven linearly designated loops between aplha and
non alpha are A to G.
The recent X ray structure of Ach suggested that
residues in all seven loops are present at the binding
sites. For ex αY198 in loop A.
These residues confer binding Ach or releasing Ach
from bound site at postsynaptic membrane.
62. Besides at the level of membrane there 5 rods typical
of alpha helices that twist upons itself to permit flow
of ion. These rods are TMD2.
TMD 2 of each alpha helices constrict upon itself to
dilate and allow flow of ions.
CMS have been found in all AchR subunits and in
several domain of subunits.
64. Slow Channel Syndromes
Recognized by Engel and co workers in 1982
Dominant inheritance
Repetitive CMAP that decremented abnormally on
RNS and prolonged synaptic response to Ach in
absence of AChE deficiency is characteristic.
Selectively involves cervical, scapular, finger extensor,
mild opthalmoparesis and variable weakness of other
muscles.
65. Clinical features.
Some present early in life and others later and progress
gradually in an intermittent manner.
Weakness usually fluctuate not as rapid as
autoimmune MG and cranial muscles are usually
spared. Muscles become atrophiccc…
69. Slow Channel Syndromes
Morphologic features
1. LM
Type 1 fiber predominance, atrophy, varying fiber size and splitting,
tubular aggregates and endomysial connective tissue deposition.
Endplate configuration is abnormal with focal deposits of calcium.
2. EM –
Junctional fold degeneration with widening of synaptic space,
degenerating and apoptotic nuclei etc. There is absence nerve
terminal in some of the postsynaptic membrane. There is also
degeneration of sarcoplasm. AchR is also lost from due destruction
of junctional fold.
72. Patch clamp analysis
Strongest proof of kinetic abnormality came from patch
clamp analysis.
There was slowing of conduction across Achr.
Molecular Genetics
Total 20 slow channel mutations have been uncovered since
1995(TMD2, αG153S etc)
Majority of slow channel results from mutation of TMD2.
73. Slow Channel Syndromes
Pathogenetic Mechanisms
Prolonged opening of AchR Increased Ca at the
junctional fold and surrounding region causes
activation of proteases and free radical productions
promotes apoptosis degeneration of junctional fold,
loss of AchR, nuclear apoptosis and features of
myopathy decreased MEPP amplitude.
74. Slow Channel Syndromes
Diagnosis
1. Clinical, dominant inheritance, normal AChE, decremental
and repetitive CMAP.
2. Invitro demonstration of slowly decaying MEPC and
abnormally prolonged opening events at AChR channels.
3. Previous DD’s were –
Mobius syndrome
peripheral neuropathy
MND
Syrings
Limb girdle dystrophy etc.
75. Slow Channel Syndromes
Treatment
1. Quinidine (200 mg 3-4 times daily) blocker of AChR
and shortens the activity of Ach.
1. Fluoxetine (up to 80 mg/ day)
76. Fast Channel Syndromes
First recognized in 1993
Derives name due to abnormal brief channel
opening events with fast decay of synaptic response.
Responds to anticholinesterase medications.
Patch clamp analysis revealed receptor opening
impaired and closing enhanced.
Proline to leucine mutation in ε subunits and
phenotype determined was εP121L.
78. Clinical Features
1. Mild gating efficacy impaired
2. Moderate channel kinetics impaired
3. Severe affinity and gating eficacy imapired.
At birth pt with severe may require ventilator support.
Pt cannot hold head erect, stand or walk
May have eyelid ptosis, facial diplegia, unable to close
mouth and dysphagia.
Sometimes arthrogroposis may develop.
80. Fast Channel Syndromes
Morphologic studies
1. Endplate morphology and AChR expression are
normal in εP121L and αV132L mutations.
2. In mutations of αV285I and ε1254ins18 mutation
AChR expression is decreased
82. Fast channel Syndromes
Diagnosis
1. In Vitro microelectrode studies showing rapidly
decaying MEPC’s
2. Genetic studies
Therapy
Combination therapy with anticholinesterases and
3,4-DAP which increases number of quanta per
release.
83.
84. Low-Expressor AChR mutations
Reduced AChR expression to < 15%
Mild to severe phenotype
Most cases mutation in ε-subunit of AchR fetal
AchR harboring γ-subunit is substituted
Mutations in both alleles of a non-ε subunit
incompatible with life
Most respond well to AChE Inh ± DAP
The described mutations are numerous (60 or more),
either homozygous or heterozygous
They are of all types: missense mutations,
chromosomal deletions, insertions, deletions.
85. •18 yo, referred as MG for a consult
before rhinoplasty
•Has always been weak in physical
activity and if doing so, fatigued
very fast.
•Fluctuating ptosis and diplopia.
•Stable and non-progressive during
these years and worse in the
evening
•Significant subjective and objective
improvement with Mestinon
86.
87. Myasthenic symptoms since infancy
Very good response to mestinon
Both have been misdiagnosed as myasthenia gravis
and both thymectomised
Mutation in CHRNE ( ε-subunit of AchR)
88.
89. Low expressor AChR mutations with no or
minor kinetic abnormality
Morphologic Studies
1. Increased no. of endplate regions distributed over an
increased span of muscle fiber.
2. No. of secondary synaptic clefts/unit length of
primary is lower and distribution of AChR on the
junctional fold is patchy.
3. Immunocytochemical reaction for rapsyn molecule
that cross links AChR is decreased.
90. Low expressor AChR mutations with no or
minor kinetic abnormality
Electrophysiological Studies
1. Amplitude of MEPP & MEPC are less but quantal
release by nerve impulse is higher.
Molecular studies
1. This results from homozygous or more frequently
heterozygous recessive mutations of AChR subunit
genes( eg. 1369delG mutation )
91. Low expressor AChR mutations with no or
minor kinetic abnormality
Treatment
1. Most patients respond well to anticholinesterase
drugs with additional benefit from 3,4-DAP
93. Rapsyn deficiency
Rapsyn under the influence of neurally supplied
agrin has a crucial role in concentrating AChR in the
postsynaptic membrane and linking it to
subsynaptic cytoskeleton through dystroglycan
Effector of agrin induced clustering of AChR.
94. Clinical Features
1. Symptoms at birth or in neonatal period and rarely in second
decade.
2. Some are born with arthrogryposis
3. Motor milestones are delayed and respiratory compromise
resulting in anoxic encephalopathy are reported
4. Facial deformities with prognathisnm is usually pronounced
in jewish population.
5. Pts have weakness of masticatory muscles, eyelid ptosis, facial
weakness and hypernasal speech.
95. Rapsyn deficiency
Morphologic features
1. Reduced expression of Rapsyn and a proportionately
reduced AChR
2. Ultrastructural studies show shallow postsynaptic
folds and clefts and smaller than normal nerve
terminals.
96. Rapsyn deficiency
Electrophysiological features
1. Decremental response maybe seen
2. Invitro reveal reduced MEPP and MEPC
Molecular studies
1. N88K E-box Rapsyn mutation is found to be
frequent cause
Treatment
1. Anticholinesterase ± 3,4-DAP
97. Sodium Channel Myasthenia
1. 20 year old normokalemic woman with abrupt attacks of respiratory and
bulbar paralysis since birth lasting 3-30 mins and recurring 1-3 times per
month.
2. She was on apnea monitor since infancy and had delayed motor milestones
3. At age 20 she had ptosis, eye movement restriction had facial,truncal and
limb weakness.
4. Had High arched palate, knock knees and lumbar lordosis
5. She was mental retarded secondary to episodic cerebral anoxia (MRI
confirmed)
6. AChR antibodies negative
100. Sodium Channel Myasthenia
Morphology studies
1. Type1 fiber was smaller
2. EM- No significant changes
3. Immunolocalization of sodium channels was
comparable with control
101. Sodium Channel Myasthenia
In vitro Electrophysiology
EPP- Normal
MEPP and Quantal EPP – Normal
Patch Clamp- Normal conductance
Molecular genetic study revealed SCN4A ( which
encodes Na) mutations
104. PLECTIN deficiency
Plectin is significantly expressed intermediate
filament linking protein which is concentrated at the
sites of mechanical stress,as post synaptic membrane ,
sarcolemma, skeletal muscle, skin.
Plectin mutations are associated with epidermolysis
bullosa, myopathy and myesthenic syndrome
105. PLECTIN deficiency
These patients with skin disease were found to have
abnormal fatigability involving ocular, facial, and limb
muscles.
Had decremental response with No antibodies
Morphology revealed necrotic and regenerative fibers with
junctional changes
AChR-Normal and Low MEPP
3,4- DAP was useful
106. Dok-7 interacts with MuSK and is essential for post-
synaptic specialization of the neuromuscular junction
DOK7 Synaptopathy
107. DOK7 Synaptopathy
Clinical features
Difficulty in walking developing after normal
motor milestones
Proximal muscles weakness > distal
Ptosis often present, EOM rarely involved
EMG always abnormal
decrement in amplitude and/or
jitter and blocking on single-fiber studies
No benefit from anticholinesterase, sometimes
worsened
Responded to ephedrine
108. Partially Characterized Syndromes
END PLATE AChR DEFIECIENCY WITH NO MUTATIONS
IN AChR OR RAPSYN
Cause of CMS obscure
? End plate specific protein defect
Familial Limb-Girdle Myasthenia
1. Autosomal recessive
2. Limb girdle weakness in childhood or teens
3. Response to anticholinesterase, No steroids
4. EMG- Decrement, MEPP- low, No AChR deficiency
109. Clinical clues pointing to a specific
diagnosis
Endplate AChE deficiency
● Repetitive CMAPs
● Refractoriness to cholinesterase inhibitors
● Delayed pupillary light reflexes
Slow-channel CMS
● Repetitive CMAPs
● Selectively severe involvement of cervical and wrist and finger
extensor muscles in most cases
● Dominant inheritance in most cases and presence of features
of myopathy
110. Clinical clues pointing …-2
Endplate choline acetyltransferase deficiency
● Recurrent apneic episodes
● No or variable myasthenic symptoms between acute episodes
● EMG decrement at 2-3 Hz can be absent at rest but appears
after stimulation at 10 Hz for 5 min, then disappears slowly.
Rapsyn deficiency
● Multiple congenital joint contractures
● Increased weakness and respiratory insufficiency precipitated
by intercurrent infections
● EMG decrement can be mild or absent.
Dok-7 myasthenia
● Proximal greater than distal limb weakness,
● mild ptosis, and normal ocular ductions in the majority
● May deteriorate on exposure to pyridostigmine
111. Pharmacotherapy
ChAT deficiency
AChE inhibitor
AChE deficiency
Avoid AChE inhibitors; ephedrine or albuterol*
Simple AChR deficiency
AChE inhibitor; 3,4-DAP also helps in 30-50%
Slow-channel CMS
Quinidine or Fluoxetine (long-lived open channel blockers)
Fast-channel CMS
AChE inhibitor and 3,4-DAP
Rapsyn deficiency
AChE inhibitor; 3,4-DAP; ephedrine or albuterol*
Na-channel myasthenia
AChE inhibitor and acetazolamide
Dok-7 myasthenia
Avoid AChE inhibitor; use ephedrine or albuterol