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dangerous to health; characterized by progressive and uncontrolled growth (especially of a tumor)
abnormally high body temperature; sometimes induced (as in treating some forms of cancer) (同)hyperthermy

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悪意のある,敵意のある / (病気が)悪性の

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2013/04/29 19:06:41」(JST)

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Malignant hyperthermia (MH) or malignant hyperpyrexia^[1] is a rare life-threatening condition that is usually triggered by exposure to certain drugs used for general anesthesia, specifically the volatile anesthetic agents and the neuromuscular blocking agent, succinylcholine. In susceptible individuals, these drugs can induce a drastic and uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if not treated quickly.

Susceptibility to MH is often inherited as an autosomal dominant disorder, for which there are at least 6 genetic loci of interest,^[2] most prominently the ryanodine receptor gene (RYR1). MH susceptibility is phenotypically and genetically related to central core disease (CCD), an autosomal dominant disorder characterized both by MH symptoms and myopathy. MH is usually revealed by anesthesia, or when a family member develops the symptoms. There is no simple, straightforward test to diagnose the condition. When MH develops during a procedure, treatment with dantrolene sodium is usually initiated; dantrolene and the avoidance of anesthesia in susceptible people have markedly reduced the mortality from this condition.

1 Classification
2 Signs and symptoms
3 Causes
- 3.1 Genetics
4 Pathophysiology
- 4.1 Disease mechanism
- 4.2 Animal model
5 Diagnosis
- 5.1 During an attack
- 5.2 Susceptibility testing
  - 5.2.1 Muscle testing
  - 5.2.2 Genetic testing
- 5.3 Criteria
6 Prevention
7 Treatment
8 Prognosis
9 Epidemiology
10 History
11 In other animals
12 References
13 External links

Classification

This condition is known by a number of names, including malignant hyperthermia (MH), malignant hyperthermia syndrome (MHS), and malignant hyperpyrexia.^[1]

Signs and symptoms

The typical symptoms of malignant hyperthermia are due to a hypercatabolic state, which presents as a very high temperature, an increased heart rate and breathing rate, increased carbon dioxide production, increased oxygen consumption, acidosis, rigid muscles, and rhabdomyolysis.^[1]

The symptoms usually develop within one hour after exposure to trigger substances, but may even occur several hours later in rare instances.^{[citation needed]}

Causes

Malignant hyperthermia is most commonly due to volatile anesthetic gases, such as halothane, sevoflurane, desflurane, isoflurane, enflurane or the depolarizing muscle relaxants suxamethonium and decamethonium used primarily in general anesthesia.^[1] Other drugs that have been suspected of causing MH include ketamine, catecholamines, phenothiazines, and monoamine oxidase inhibitors. There are also few reports of MH being triggered by nitrous oxide administration. ^[3] In rare cases, the biological stresses of physical exercise or heat may be the trigger.^[1]

Other anesthetic drugs are considered safe.^{[citation needed]} These include local anesthetics (lidocaine, bupivicaine, mepivacaine), opiates (morphine, fentanyl), ketamine, barbiturates, nitrous oxide, propofol, etomidate, benzodiazepines.

The nondepolarizing muscle relaxants pancuronium, cisatracurium, atracurium, mivacurium, vecuronium and rocuronium also do not cause MH.

Genetics

Malignant hyperthermia's inheritance is autosomal dominant.^[1] The defect is typically located on the long arm of chromosome 19 (19q13.1) involving the ryanodine receptor.^[1] More than 25 different mutations in this gene are linked with malignant hyperthermia.^[1] These mutations tend to cluster in one of three domains within the protein, designated MH1-3. MH1 and MH2 are located in the N-terminus of the protein, which interacts with L-type calcium channels and Ca²⁺. MH3 is located in the transmembrane forming C-terminus. This region is important for allowing Ca²⁺ passage through the protein following opening.^{[citation needed]}

Chromosome 7q and chromosome 17 have also been implicated. It has also been postulated that MH and central core disease may be allelic and thus can be co-inherited.

Pathophysiology

Disease mechanism

In a large proportion (50–70%) of cases, the propensity for malignant hyperthermia is due to a mutation of the ryanodine receptor (type 1), located on the sarcoplasmic reticulum (SR), the organelle within skeletal muscle cells that stores calcium.^[4]^[5] RYR1 opens in response to increases in intracellular Ca²⁺ level mediated by L-type calcium channels, thereby resulting in a drastic increase in intracellular calcium levels and muscle contraction. RYR1 has two sites believed to be important for reacting to changing Ca²⁺ concentrations: the A-site and the I-site. The A-site is a high affinity Ca²⁺ binding site that mediates RYR1 opening. The I-site is a lower affinity site that mediates the protein's closing. Caffeine, halothane, and other triggering agents act by drastically increasing the affinity of the A-site for Ca²⁺ and concomitantly decreasing the affinity of the I-site in mutant proteins. Mg²⁺ also affect RYR1 activity, causing the protein to close by acting at either the A- or I-sites. In MH mutant proteins, the affinity for Mg²⁺ at either one of these sites is greatly reduced. The end result of these alterations is greatly increased Ca²⁺ release due to a lowered activation and heightened deactivation threshold.^[6]^[7] The process of sequestering this excess Ca²⁺ consumes large amounts of adenosine triphosphate (ATP), the main cellular energy carrier, and generates the excessive heat (hyperthermia) that is the hallmark of the disease. The muscle cell is damaged by the depletion of ATP and possibly the high temperatures, and cellular constituents "leak" into the circulation, including potassium, myoglobin, creatine, phosphate and creatine kinase.

The other known causative gene for MH is CACNA1S, which encodes an L-type voltage-gated calcium channel α-subunit. There are two known mutations in this protein, both affecting the same residue, R1086.^[8]^[9] This residue is located in the large intracellular loop connecting domains 3 and 4, a domain possibly involved in negatively regulating RYR1 activity. When these mutant channels are expressed in human embryonic kidney (HEK 293) cells, the resulting channels are five times more sensitive to activation by caffeine (and presumably halothane) and activate at 5–10mV more hyperpolarized. Furthermore, cells expressing these channels have an increased basal cytosolic Ca²⁺ concentration. As these channels interact with and activate RYR1, these alterations result in a drastic increase of intracellular Ca²⁺, and, thereby, muscle excitability.^[10]

Other mutations causing MH have been identified, although in most cases the relevant gene remains to be identified.^[2]

Animal model

Research into malignant hyperthermia was limited until the discovery of "porcine stress syndrome" (PSS) in Danish Landrace and other pig breeds selected for muscling, a condition in which stressed pigs develop "pale, soft, exudative" flesh (a manifestation of the effects of malignant hyperthermia) rendering their meat less marketable at slaughter. This "awake triggering" was not observed in humans, and initially cast doubts on the value of the animal model, but subsequently, susceptible humans were discovered to "awake trigger" (develop malignant hyperthermia) in stressful situations. This supported the use of the pig model for research. Pig farmers use halothane cones in swine yards to expose piglets to halothane. Those that die were MH-susceptible, thus saving the farmer the expense of raising a pig whose meat he would not be able to market. This also reduced the use of breeding stock carrying the genes for PSS. The condition in swine is also due to a defect in ryanodine receptors.^[11]

Gillard et al. discovered the causative mutation in humans only after similar mutations had first been described in pigs.^[4]

Horses also suffer from malignant hyperthermia. A causative mutated allele, ryanodine receptor 1 gene (RyR1) at nucleotide C7360G, generating a R2454G amino acid substitution.^[12] has been identified in the American Quarter Horse and breeds with Quarter Horse ancestry, inherited as an autosomal dominant^[13]^[14] It can be caused by overwork, anesthesia, or stress. ^[15] In dogs, its inheritance is autosomal recessive.^[1]

An MH mouse has been constructed, bearing the R163C mutation prevalent in humans. These mice display symptoms similar to human MH patients, including sensitivity to halothane (increased respiration, body temperature, and death). Blockade of RYR1 by dantrolene prevents adverse reaction to halothane in these mice, as with humans. Muscle from these mice also shows increased K⁺-induced depolarization and an increased caffeine sensitivity.^[16]

Diagnosis

During an attack

The earliest signs are early masseter muscle contracture following administration of succinylcholine, a rise in end-tidal carbon dioxide concentration (despite increased minute ventilation), unexplained tachycardia, and muscle rigidity.^[1] Despite the name, elevation of body temperature is often a late sign. Other signs may include acidosis, tachypnea (in a spontaneously breathing patient), cyanosis, hypertension, cardiac dysrhythmias and hyperkalemia. Core body temperatures should be measured in any patient undergoing general anesthesia longer than 20 minutes.

Malignant hyperthermia is diagnosed on clinical grounds, but various investigations are generally performed. This includes blood tests, which may show a raised creatine kinase level, elevated potassium, increased phosphate (leading to decreased calcium) and—if determined—raised myoglobin; this is the result of damage to muscle cells. Metabolic acidosis and respiratory acidosis (raised acidity of the blood) may both occur. Severe rhabdomyolysis may lead to acute renal failure, so kidney function is generally measured on a frequent basis. Patients may also get cardiac arrythmias (PVCs) due to the increased levels of potassium released from the muscles during episodes.^{[citation needed]}

Susceptibility testing

In those who have experienced an episode of MH, further testing is not usually useful, as even a normal test does not mean there is no risk of recurrence. The exception would be if it is unclear whether the initial attack was due to a different medical problem, such as sepsis.^{[citation needed]}

Muscle testing

The main candidates for testing are those with a close relative who has suffered an episode of MH or has been shown to be susceptible. The standard procedure is the "caffeine-halothane contracture test", CHCT. A muscle biopsy is carried out at an approved research center, under local anesthesia. The fresh biopsy is bathed in solutions containing caffeine or halothane and observed for contraction; under good conditions, the sensitivity is 97% and the specificity 78%.^[17] Negative biopsies are not definitive, so any patient who is suspected of MH by their medical history or that of blood relatives is generally treated with nontriggering anesthetics, even if the biopsy was negative. Some researchers advocate the use of the "calcium-induced calcium release" test in addition to the CHCT to make the test more specific.^{[citation needed]}

Less invasive diagnostic techniques have been proposed. Intramuscular injection of halothane 6 vol% has been shown to result in higher than normal increases in local pCO₂ among patients with known malignant hyperthermia susceptibility. The sensitivity was 100% and specificity was 75%. For patients at similar risk to those in this study, this leads to a positive predictive value of 80% and negative predictive value of 100%. This method may provide a suitable alternative to more invasive techniques.^[18] A 2002 study examined another possible metabolic test. In this test, intramuscular injection of caffeine was followed by local measurement of the pCO₂; those with known MH susceptibility had a significantly higher pCO₂ (63 versus 44 mmHg). The authors propose larger studies to assess the test's suitability for determining MH risk.^[19]

Genetic testing

Genetic testing is being performed in a limited fashion to determine susceptibility to MH.^[1] In people with a family history of MH, analysis for RYR1 mutations maybe useful.^[2]

Criteria

A 1994 consensus conference led to the formulation of a set of diagnostic criteria. The higher the score (above 6), the more likely a reaction constituted MH:^[20]

Respiratory acidosis (end-tidal CO₂ above 55 mmHg/7.32 kPa or arterial pCO₂ above 60 mmHg/7.98 kPa)
Heart involvement (unexplained sinus tachycardia, ventricular tachycardia or ventricular fibrillation)
Metabolic acidosis (base excess lower than -8, pH <7.25)
Muscle rigidity (generalized rigidity including severe masseter muscle rigidity)
Muscle breakdown (CK >20,000/L units, cola colored urine or excess myoglobin in urine or serum, potassium above 6 mmol/l)
Temperature increase (rapidly increasing temperature, T >38.8°C)
Other (rapid reversal of MH signs with dantrolene, elevated resting serum CK levels)
Family history (autosomal dominant pattern)

Prevention

In the past, the prophylactic use of dantrolene was recommended for MH susceptible patients undergoing general anesthesia.^[21] However, multiple retrospective studies have demonstrated the safety of trigger-free general anesthesia in these patients in the absence of prophylactic dantrolene administration. The largest of these studies looked at the charts of 2214 patients who underwent general or regional anesthesia for an elective muscle biopsy. About half (1082) of the patients were muscle biopsy positive for MH. Only five of these patients exhibited symptoms consistent with MH, four of which were treated successfully with parenteral dantrolene, and the remaining one recovered with only symptomatic therapy.^[22] After weighing its questionable benefits against its possible adverse effects (including nausea, vomiting, muscle weakness and prolonged duration of action of nondepolarising neuromuscular blocking agents^[23]), experts no longer recommend the use of prophylactic dantrolene prior to trigger-free general anesthesia in MH susceptible patients.^[21]

Anaesthesia for known MH susceptible patients requires avoidance of triggering agents (all volatile anaesthetic agents and succinylcholine). All other drugs are safe (including nitrous oxide), as are regional anaesthetic techniques. Where general anaesthesia is planned, it can be provided safely by removing vaporisers from the anaesthetic machine, placing a new breathing circuit on the machine, flushing the machine and ventilator with 100% oxygen at maximal gas flows for 20–30 minutes, and inducing and maintaining anaesthesia with nontriggering agents (e.g.: propofol).^[23] Modern anaesthetic machines have more rubber and plastic components which provide a reservoir for volatile anaesthetics, and should be flushed for 60 minutes.^[24]

Treatment

Dantrolene sodium, the only available medical treatment for malignant hyperthermia

The current treatment of choice is the intravenous administration of dantrolene, the only known antidote, discontinuation of triggering agents, and supportive therapy directed at correcting hyperthermia, acidosis, and organ dysfunction. Treatment must be instituted rapidly on clinical suspicion of the onset of malignant hyperthermia.^[23]

Dantrolene is a muscle relaxant that appears to work directly on the ryanodine receptor to prevent the release of calcium. After the widespread introduction of treatment with dantrolene, the mortality of malignant hyperthermia fell from 80% in the 1960s to less than 10%. Dantrolene remains the only drug known to be effective in the treatment of MH.^[21]

Its clinical use has been limited by its low water solubility, leading to requirements of large fluid volumes, which may complicate clinical management. Azumolene is a 30-fold more water-soluble analogue of dantrolene that also works to decrease the release of intracellular calcium by its action on the ryanodine receptor. In MH susceptible swine, azumolene was as potent as dantrolene.^[25] It has yet to be studied in vivo in humans, but may present a suitable alternative to dantrolene in the treatment of MH.

Research in mouse models suggests that azumolene "is likely uncoupling the efficiency of a Ca²⁺-dependent RyR1 signal coupled directly or indirectly to the [store-operated calcium entry] machinery." There may be two different pathways of store-operated calcium entry: one, RyR1-reliant and the other, RyR1-non-reliant (see Disease Mechanism section above for RyR1 description). Furthermore, elucidating earlier ideas on the pathogenesis of malignant hyperthermia, researchers point out that it may be "as much a syndrome of exaggerated Ca²⁺ entry as it is of exaggerated Ca²⁺ release."^[26]

Azumolene has also been shown to be as effective as dantrolene at preventing and reversing contracture in in vitro experiments with human skeletal muscle.^[27]

Prognosis

Prognosis is poor if this condition is not aggressively treated.^[1] In the 1970s, mortality was greater than 80%; with the current management, however, mortality is now less than 5%.^[1]

Epidemiology

The incidence is between 1:5,000 to 1:50,000–100,000 procedures involving general anaesthesia.^[1] This disorder occurs worldwide and affects all racial groups. Most cases, however, occur in children and young adults, which might be related to the fact many older people will have already had surgeries and thus would know about and be able to avoid this condition.^{[citation needed]}

History

The syndrome was first recognized in Australia in an affected family by Denborough et al. in 1962.^[28] Denborough did much of his subsequent work on the condition at the Royal Canberra Hospital.^[29] Similar reactions were found in pigs.^[30] The efficacy of dantrolene as a treatment was discovered by South African anesthesiologist Gaisford Harrison and reported in a 1975 article published in the British Journal of Anaesthesia.^[31] After further animal studies corroborated the possible benefit from dantrolene, a 1982 study confirmed its usefulness in humans.^[32]

In other animals

Other animal including certain pig breeds, dogs, and horses are susceptible to malignant hyperthermia.^[1] In dogs its inheritance is autosomal recessive.^[1]

References

^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p Rosenberg H, Davis M, James D, Pollock N, Stowell K (2007). "Malignant hyperthermia". Orphanet J Rare Dis 2: 21. doi:10.1186/1750-1172-2-21. PMC 1867813. PMID 17456235.
^ ^a ^b ^c Litman R, Rosenberg H (2005). "Malignant hyperthermia: update on susceptibility testing". JAMA 293 (23): 2918–24. doi:10.1001/jama.293.23.2918. PMID 15956637.
^ PD Waite (1985). "Malignant hyperthermia in a patient receiving nitrous oxide". Journal of Oral and Maxillofacial Surgery 43 (11): 907–909. PMID 3863903.
^ ^a ^b Gillard E, Otsu K, Fujii J, Khanna V, de Leon S, Derdemezi J, Britt B, Duff C, Worton R, MacLennan D (1991). "A substitution of cysteine for arginine 614 in the ryanodine receptor is potentially causative of human malignant hyperthermia". Genomics 11 (3): 751–5. doi:10.1016/0888-7543(91)90084-R. PMID 1774074.
^ Galli L, Orrico A, Lorenzini S, Censini S, Falciani M, Covacci A, Tegazzin V, Sorrentino V (2006). "Frequency and localization of mutations in the 106 exons of the RYR1 gene in 50 individuals with malignant hyperthermia". Hum Mutat 27 (8): 830. doi:10.1002/humu.9442. PMID 16835904.
^ Balog E, Fruen B, Shomer N, Louis C (2001). "Divergent effects of the malignant hyperthermia-susceptible Arg(615)-->Cys mutation on the Ca(2+) and Mg(2+) dependence of the RyR1". Biophys J 81 (4): 2050–8. Bibcode:2001BpJ....81.2050B. doi:10.1016/S0006-3495(01)75854-7. PMC 1301678. PMID 11566777.
^ Yang T, Ta T, Pessah I, Allen P (2003). "Functional defects in six ryanodine receptor isoform-1 (RyR1) mutations associated with malignant hyperthermia and their impact on skeletal excitation-contraction coupling". J Biol Chem 278 (28): 25722–30. doi:10.1074/jbc.M302165200. PMID 12732639.
^ Monnier N, Procaccio V, Stieglitz P, Lunardi J (1997). "Malignant-hyperthermia susceptibility is associated with a mutation of the alpha 1-subunit of the human dihydropyridine-sensitive L-type voltage-dependent calcium-channel receptor in skeletal muscle". Am J Hum Genet 60 (6): 1316–25. doi:10.1086/515454. PMC 1716149. PMID 9199552.
^ The R1086C mutant has never been published, but has nevertheless been referenced multiple times in the literature, e.g. Jurkat-Rott K, McCarthy T, Lehmann-Horn F (2000). "Genetics and pathogenesis of malignant hyperthermia". Muscle Nerve 23 (1): 4–17. doi:10.1002/(SICI)1097-4598(200001)23:1<4::AID-MUS3>3.0.CO;2-D. PMID 10590402.
^ Weiss R, O'Connell K, Flucher B, Allen P, Grabner M, Dirksen R (2004). "Functional analysis of the R1086H malignant hyperthermia mutation in the DHPR reveals an unexpected influence of the III-IV loop on skeletal muscle EC coupling". Am J Physiol Cell Physiol 287 (4): C1094–102. doi:10.1152/ajpcell.00173.2004. PMID 15201141.
^ J Fujii, K Otsu, F Zorzato, S de Leon, VK Khanna, JE Weiler, PJ O'Brien and DH MacLennan (1991). "Identification of a mutation in porcine ryanodine receptor associated with malignant hyperthermia". Science 253 (5018): 448–451. Bibcode:1991Sci...253..448F. doi:10.1126/science.1862346. PMID 1862346.
^ Aleman M, Nieto JE, Magdesian KG (2009). "Malignant hyperthermia associated with ryanodine receptor 1 (C7360G) mutation in Quarter Horses". J. Vet. Intern. Med. 23 (2): 329–34. doi:10.1111/j.1939-1676.2009.0274.x. PMID 19220734.
^ http://manc.umd.edu/Abstracts2010/LenzHYPP%20abstract.pdf
^ ftp://ftp.aave.inv.org.ar/IVIS/aaep/Equine%20Malignant%20Hyperthermia.pdf
^ Valberg SJ, Mickelson JR, Gallant EM, MacLeay JM, Lentz L, de la Corte F (1999). "Exertional rhabdomyolysis in quarter horses and thoroughbreds: one syndrome, multiple aetiologies". Equine Vet J Suppl 30: 533–8. PMID 10659313.
^ Yang T, Riehl J, Esteve E et al. (2006). "Pharmacologic and functional characterization of malignant hyperthermia in the R163C RyR1 knock-in mouse". Anesthesiology 105 (6): 1164–75. doi:10.1097/00000542-200612000-00016. PMID 17122579.
^ Allen G, Larach M, Kunselman A (1998). "The sensitivity and specificity of the caffeine-halothane contracture test: a report from the North American Malignant Hyperthermia Registry". Anesthesiology 88 (3): 579–88. doi:10.1097/00000542-199803000-00006. PMID 9523799.
^ Schuster F, Gardill A, Metterlein T, Kranke P, Roewer N, Anetseder M (2007). "A minimally invasive metabolic test with intramuscular injection of halothane 5 and 6 vol% to detect probands at risk for malignant hyperthermia". Anaesthesia 62 (9): 882–7. doi:10.1111/j.1365-2044.2007.05173.x. PMID 17697213.
^ Anetseder M, Hager M, Müller CR, Roewer N (2002). "Diagnosis of susceptibility to malignant hyperthermia by use of a metabolic test". Lancet 359 (9317): 1579–80. doi:10.1016/S0140-6736(02)08506-9. PMID 12047971.
^ Larach MG, Localio AR, Allen GC et al. (1994). "A clinical grading scale to predict malignant hyperthermia susceptibility". Anesthesiology 80 (4): 771–9. doi:10.1097/00000542-199404000-00008. PMID 8024130.
^ ^a ^b ^c Krause T, Gerbershagen MU, Fiege M, Weisshorn R, Wappler F (2004). "Dantrolene--a review of its pharmacology, therapeutic use and new developments". Anaesthesia 59 (4): 364–73. doi:10.1111/j.1365-2044.2004.03658.x. PMID 15023108.
^ Carr AS, Lerman J, Cunliffe M, McLeod ME, Britt BA (1995). "Incidence of malignant hyperthermia reactions in 2,214 patients undergoing muscle biopsy". Can J Anaesth 42 (4): 281–6. doi:10.1007/BF03010703. PMID 7788824.
^ ^a ^b ^c Halsall PJ, Hopkins PM (2003). "Malignant hyperthermia". Continuing Education in Anaethesia, Critical Care and Pain 3 (1): 5–9. doi:10.1093/bjacepd/mkg002.
^ Kim Tae W., Nemergut, ME (2011). "Preparation of Modern Anesthesia Workstations for Malignant Hyperthermia–susceptible Patients: A Review of Past and Present Practice". Anesthesiology 114 (1): 205–212. doi:10.1097/ALN.0b013e3181ee2cb7. PMID 21169802.
^ Dershwitz M, Sréter FA (1990). "Azumolene reverses episodes of malignant hyperthermia in susceptible swine". Anesth. Analg. 70 (3): 253–5. doi:10.1213/00000539-199003000-00004. PMID 2305975.
^ Zhao X, Weisleder N, Han X, Pan Z, Parness J, Brotto M, Ma J (2006). "Azumolene Inhibits a Component of Store-operated Calcium Entry Coupled to the Skeletal Muscle Ryanodine Receptor". The Journal of Biological Chemistry 281 (44): 33477–86. doi:10.1074/jbc.M602306200. PMID 16945924.
^ Sudo RT, Carmo, PL, Trachez MM, Pan Z, Zapata-Sudo G (2008). "Effects of Azumolene on Normal and Malignant Hyperthermia-Susceptible Skeletal Muscle". Basic & Clinical Pharmacology and Toxicology 102 (3): 308–16. doi:10.1111/j.1742-7843.2007.00156.x. PMID 18047479.
^ Denborough MA, Forster JF, Lovell RR, Maplestone PA, Villiers JD (1962). "Anaesthetic deaths in a family". British Journal of Anaesthesia 34 (6): 395–6. doi:10.1093/bja/34.6.395. PMID 13885389. Historical account in Denborough MA (2008). "Malignant hyperthermia. 1962". Anesthesiology 108 (1): 156–7. doi:10.1097/01.anes.0000296107.23210.dd. PMID 18156894.
^ Malcolm Whyte. 'Clinical Science in Canberra Hospital' in AJ Proust (ed) History of Medicine in Canberra and Queanbeyan and their Hospitals Brolga Press, Gundaroo p123 at 127
^ Hall LW, Woolf N, Bradley JW, Jolly DW (1966). "Unusual reaction to suxamethonium chloride". Br Med J 2 (5525): 1305. doi:10.1136/bmj.2.5525.1305. PMC 1944316. PMID 5924819.
^ Harrison GG (January 1975). "Control of the malignant hyperpyrexic syndrome in MHS swine by dantrolene sodium". British Journal of Anaesthesia 47 (1): 62–5. doi:10.1093/bja/47.1.62. PMID 1148076. A reprint of the article, which became a "Citation Classic", is available in Br J Anaesth81 (4): 626–9. PMID 9924249 (free full text).
^ Kolb ME, Horne ML, Martz R (1982). "Dantrolene in human malignant hyperthermia". Anesthesiology 56 (4): 254–62. doi:10.1097/00000542-198204000-00005. PMID 7039419.

External links

GeneReview/NIH/UW entry on Malignant Hyperthermia Susceptibility
Malignant Hyperthermia Association of the United States
Making Anesthesia Safer - Unraveling the Malignant Hyperthermia Puzzle by Marilyn Green Larach, FASEB "Breakthroughs in Bioscience"

UpToDate Contents

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1. 悪性高熱症：臨床診断および急性期のマネージメント malignant hyperthermia clinical diagnosis and management of acute crisis
2. 悪性高熱症の易罹患性：評価およびマネージメント susceptibility to malignant hyperthermia evaluation and management
3. 悪性症候群 neuroleptic malignant syndrome
4. 薬物熱 drug fever
5. 成人における迅速導入気管挿管のための神経筋遮断剤（NMBA） neuromuscular blocking agents nmba for rapid sequence intubation in adults

English Journal

Cystathionine β-synthase-derived hydrogen sulfide is involved in human malignant hyperthermia.

Vellecco V1, Mancini A2, Ianaro A1, Calderone V3, Attanasio C4, Cantalupo A5, Andria B2, Savoia G6, Panza E1, Di Martino A2, Cirino G7, Bucci M1.
Clinical science (London, England : 1979).Clin Sci (Lond).2016 Jan 1;130(1):35-44. doi: 10.1042/CS20150521. Epub 2015 Oct 12.
Hydrogen sulfide is an endogenous gasotransmitter and its mechanism of action involves activation of ATP-sensitive K(+) channels and phosphodiesterase inhibition. As both mechanisms are potentially involved in malignant hyperthermia (MH), in the present study we addressed the involvement of the L-cy
PMID 26460077

A Case of Malignant Hyperthermia Captured by Neuromonitoring During a Lumbar Endoscopic Discectomy.

Galgano M1, Briggs D, Marawar S, Calancie B.
Journal of neurosurgical anesthesiology.J Neurosurg Anesthesiol.2016 Jan;28(1):86-87.
PMID 26291728

Monocytic delivery of therapeutic oxygen bubbles for dual-modality treatment of tumor hypoxia.

Huang WC1, Shen MY2, Chen HH3, Lin SC3, Chiang WH1, Wu PH1, Chang CW1, Chiang CS1, Chiu HC4.
Journal of controlled release : official journal of the Controlled Release Society.J Control Release.2015 Dec 28;220(Pt B):738-50. doi: 10.1016/j.jconrel.2015.09.016. Epub 2015 Sep 12.
Photodynamic therapy (PDT) is a powerful technique photochemically tailored for activating apoptosis of malignant cells. Although PDT has shown promise in several clinical applications, malignant cells in hypoxic regions are often resistant to PDT due to the transport limitation of therapeutics and
PMID 26374945

Japanese Journal

悪性症候群と悪性高熱 (特集体温 : 測定から管理まで) -- (病因としての体温異常)

杉田学
救急医学 = The Japanese journal of acute medicine 37(9), 1046-1051, 2013-09
NAID 40019803842

症例セボフルラン麻酔を用いた気管支喘息大発作の治療中に悪性高熱症を疑わせた1例

菅健敬,中條悟,高原賢守 [他]
ICUとCCU = Japanese journal of intensive care medicine : 集中治療医学 37(7), 551-556, 2013-07
NAID 40019777444

Exome sequencing reveals SCO2 mutations in a family presented with fatal infantile hyperthermia

Sambuughin Nyamkhishig,Liu Xinyue,Bijarnia Sunita [他]
Journal of human genetics 58(4), 226-228, 2013-04
NAID 40019636844

Related Pictures

★リンクテーブル★

リンク元	「スキサメトニウム」「悪性高熱症」「MH」「悪性過高熱」
関連記事	「hyperthermia」「malignant」

「スキサメトニウム」

Malignant hyperthermia
	Classification and external resources
	; Abnormalities in the Ryanodine receptor 1 gene are commonly detected in malignant hyperthermia
ICD-10	T88.3
ICD-9	995.86
OMIM	145600 154275 154276 600467 601887 601888
DiseasesDB	7776
MedlinePlus	001315
MeSH	D008305
GeneReviews	Malignant Hyperthermia Susceptibility;

　　[★]

英: suxamethonium
同: サクシニルコリン succinylcholine、塩化サクシニルコリン succinylcholine chloride, SCC
化: 塩化スキサメトニウム　 suxamethonium chloride
商: サクシン、レラキシン、Anectin
関: 薬理学

[show details]

スキサメトニウム : 約 4,120 件
サクシニルコリン : 約 1,860 件

分類

筋弛緩薬

脱分極性筋弛緩薬

構造

作用機序

アセチルコリン受容体に結合してシナプス後膜を脱分極したままにし、興奮伝達を遮断する。

薬理作用

動態

血漿中及び肝臓のpseudocholine esterase(偽ChE)によって分解されるので、持続時間が5分と短い

適応

麻酔時の筋弛緩

気管内挿管時・骨折脱臼の整復時・喉頭痙攣の筋弛緩

精神神経科における電撃療法の際の筋弛緩

腹部腫瘤診断時

注意

禁忌

副作用

SAN.71改変

1. 筋肉痛：強い攣縮が起こるために筋痛をきたす。

a) 外眼筋攣縮：眼圧亢進を来たし、緑内障を生ずることがある。この眼圧亢進は投与後1-6分で5-10mmHgほど上昇
b) 脳圧亢進
c) 腹筋の攣縮：胃内圧亢進を来たす。

2. 副交感神経刺激：アセチルコリンと同様の作用を有する　→　ムスカリン作用が強く出現し、徐脈、不整脈を起こしやすい
3. 高カルシウム血症
4. 悪性過高熱(malignant hyperthermia, 悪性高熱)

治療：ダントロレン：筋小胞体からのカルシウム遊離を阻害

「悪性高熱症」

　　[★]

pyrexia
英: malignant hyperpyrexia, MH
同: 悪性高体温症 malignant hyperthermia
関: 悪性高熱

周術期管理学 091127III

病因

薬剤：ハロセンとスキサメトニウム(サクシニルコリン)の併用で発生することがある

(最も多い)

吸入麻酔薬(ハロセンが最も多い)
脱分極性筋弛緩薬(サクシニルコリン)

(起こりにくい)

プロポフォール
麻薬
普通の鎮痛薬
非脱分極性筋弛緩薬(ロクロニウム、ベクロニウム)

病態生理

骨格筋内の筋小胞体からのカルシウムイオンの異常な遊離亢進により筋強直

小胞体のカルシウムチャネルにおけるアミノ酸配列に異常が見られることによる

症状

高熱(40℃以上)、筋硬直、頻脈、不整脈、高度のアシドーシス、多臓器不全

診断

診断基準

15分間で0.5℃以上 or 1時間で1℃以上の体温の上昇
発症後にミオグロビン尿が見られる
ETCO2の上昇

鑑別疾患

発症が疑われたとき

疑わしい薬物の投与中止
発熱がある場合は、ダントロレンを投与
冷却(大量輸血、対外循環)
輸液(アシドーシス・電解質の補正)
利尿剤の投与

治療

麻酔の中止
純酸素の吸入
全身を冷却
対ショック療法
ダントロレンの投与

「MH」

　　[★]

「悪性過高熱」

　　[★]

英: malignant hyperthermia

「hyperthermia」

　　[★]

n.

高熱、体温上昇、高体温、高熱症、(治療法)温熱療法

「malignant」

　　[★]

adj.

悪性の

関: malignantly、pernicious

[Rosen2007-1] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p Rosenberg H, Davis M, James D, Pollock N, Stowell K (2007). "Malignant hyperthermia". Orphanet J Rare Dis 2: 21. doi:10.1186/1750-1172-2-21. PMC 1867813. PMID 17456235.

[Litman_2005-2] Litman R, Rosenberg H (2005). "Malignant hyperthermia: update on susceptibility testing". JAMA 293 (23): 2918–24. doi:10.1001/jama.293.23.2918. PMID 15956637.

[3] PD Waite (1985). "Malignant hyperthermia in a patient receiving nitrous oxide". Journal of Oral and Maxillofacial Surgery 43 (11): 907–909. PMID 3863903.

[Gillard_1991-4] Gillard E, Otsu K, Fujii J, Khanna V, de Leon S, Derdemezi J, Britt B, Duff C, Worton R, MacLennan D (1991). "A substitution of cysteine for arginine 614 in the ryanodine receptor is potentially causative of human malignant hyperthermia". Genomics 11 (3): 751–5. doi:10.1016/0888-7543(91)90084-R. PMID 1774074.

[Galli_2006-5] Galli L, Orrico A, Lorenzini S, Censini S, Falciani M, Covacci A, Tegazzin V, Sorrentino V (2006). "Frequency and localization of mutations in the 106 exons of the RYR1 gene in 50 individuals with malignant hyperthermia". Hum Mutat 27 (8): 830. doi:10.1002/humu.9442. PMID 16835904.

[Balog_2001-6] Balog E, Fruen B, Shomer N, Louis C (2001). "Divergent effects of the malignant hyperthermia-susceptible Arg(615)-->Cys mutation on the Ca(2+) and Mg(2+) dependence of the RyR1". Biophys J 81 (4): 2050–8. Bibcode:2001BpJ....81.2050B. doi:10.1016/S0006-3495(01)75854-7. PMC 1301678. PMID 11566777.

[Yang_2003-7] Yang T, Ta T, Pessah I, Allen P (2003). "Functional defects in six ryanodine receptor isoform-1 (RyR1) mutations associated with malignant hyperthermia and their impact on skeletal excitation-contraction coupling". J Biol Chem 278 (28): 25722–30. doi:10.1074/jbc.M302165200. PMID 12732639.

[Monnier_1997-8] Monnier N, Procaccio V, Stieglitz P, Lunardi J (1997). "Malignant-hyperthermia susceptibility is associated with a mutation of the alpha 1-subunit of the human dihydropyridine-sensitive L-type voltage-dependent calcium-channel receptor in skeletal muscle". Am J Hum Genet 60 (6): 1316–25. doi:10.1086/515454. PMC 1716149. PMID 9199552.

[unknown-9] The R1086C mutant has never been published, but has nevertheless been referenced multiple times in the literature, e.g. Jurkat-Rott K, McCarthy T, Lehmann-Horn F (2000). "Genetics and pathogenesis of malignant hyperthermia". Muscle Nerve 23 (1): 4–17. doi:10.1002/(SICI)1097-4598(200001)23:1<4::AID-MUS3>3.0.CO;2-D. PMID 10590402.

[Weiss_2004-10] Weiss R, O'Connell K, Flucher B, Allen P, Grabner M, Dirksen R (2004). "Functional analysis of the R1086H malignant hyperthermia mutation in the DHPR reveals an unexpected influence of the III-IV loop on skeletal muscle EC coupling". Am J Physiol Cell Physiol 287 (4): C1094–102. doi:10.1152/ajpcell.00173.2004. PMID 15201141.

[11] J Fujii, K Otsu, F Zorzato, S de Leon, VK Khanna, JE Weiler, PJ O'Brien and DH MacLennan (1991). "Identification of a mutation in porcine ryanodine receptor associated with malignant hyperthermia". Science 253 (5018): 448–451. Bibcode:1991Sci...253..448F. doi:10.1126/science.1862346. PMID 1862346.

[12] Aleman M, Nieto JE, Magdesian KG (2009). "Malignant hyperthermia associated with ryanodine receptor 1 (C7360G) mutation in Quarter Horses". J. Vet. Intern. Med. 23 (2): 329–34. doi:10.1111/j.1939-1676.2009.0274.x. PMID 19220734.

[13] ttp://manc.umd.edu/Abstracts2010/LenzHYPP%20abstract.pdf

[14] tp://ftp.aave.inv.org.ar/IVIS/aaep/Equine%20Malignant%20Hyperthermia.pdf

[pmid10659313-15] Valberg SJ, Mickelson JR, Gallant EM, MacLeay JM, Lentz L, de la Corte F (1999). "Exertional rhabdomyolysis in quarter horses and thoroughbreds: one syndrome, multiple aetiologies". Equine Vet J Suppl 30: 533–8. PMID 10659313.

[Yang_2006-16] Yang T, Riehl J, Esteve E et al. (2006). "Pharmacologic and functional characterization of malignant hyperthermia in the R163C RyR1 knock-in mouse". Anesthesiology 105 (6): 1164–75. doi:10.1097/00000542-200612000-00016. PMID 17122579.

[Allen_1998-17] Allen G, Larach M, Kunselman A (1998). "The sensitivity and specificity of the caffeine-halothane contracture test: a report from the North American Malignant Hyperthermia Registry". Anesthesiology 88 (3): 579–88. doi:10.1097/00000542-199803000-00006. PMID 9523799.

[pmid17697213-18] Schuster F, Gardill A, Metterlein T, Kranke P, Roewer N, Anetseder M (2007). "A minimally invasive metabolic test with intramuscular injection of halothane 5 and 6 vol% to detect probands at risk for malignant hyperthermia". Anaesthesia 62 (9): 882–7. doi:10.1111/j.1365-2044.2007.05173.x. PMID 17697213.

[19] Anetseder M, Hager M, Müller CR, Roewer N (2002). "Diagnosis of susceptibility to malignant hyperthermia by use of a metabolic test". Lancet 359 (9317): 1579–80. doi:10.1016/S0140-6736(02)08506-9. PMID 12047971.

[20] Larach MG, Localio AR, Allen GC et al. (1994). "A clinical grading scale to predict malignant hyperthermia susceptibility". Anesthesiology 80 (4): 771–9. doi:10.1097/00000542-199404000-00008. PMID 8024130.

[Krause-21] Krause T, Gerbershagen MU, Fiege M, Weisshorn R, Wappler F (2004). "Dantrolene--a review of its pharmacology, therapeutic use and new developments". Anaesthesia 59 (4): 364–73. doi:10.1111/j.1365-2044.2004.03658.x. PMID 15023108.

[22] Carr AS, Lerman J, Cunliffe M, McLeod ME, Britt BA (1995). "Incidence of malignant hyperthermia reactions in 2,214 patients undergoing muscle biopsy". Can J Anaesth 42 (4): 281–6. doi:10.1007/BF03010703. PMID 7788824.

[Halsall_2003-23] Halsall PJ, Hopkins PM (2003). "Malignant hyperthermia". Continuing Education in Anaethesia, Critical Care and Pain 3 (1): 5–9. doi:10.1093/bjacepd/mkg002.

[24] Kim Tae W., Nemergut, ME (2011). "Preparation of Modern Anesthesia Workstations for Malignant Hyperthermia–susceptible Patients: A Review of Past and Present Practice". Anesthesiology 114 (1): 205–212. doi:10.1097/ALN.0b013e3181ee2cb7. PMID 21169802.

[25] Dershwitz M, Sréter FA (1990). "Azumolene reverses episodes of malignant hyperthermia in susceptible swine". Anesth. Analg. 70 (3): 253–5. doi:10.1213/00000539-199003000-00004. PMID 2305975.

[26] Zhao X, Weisleder N, Han X, Pan Z, Parness J, Brotto M, Ma J (2006). "Azumolene Inhibits a Component of Store-operated Calcium Entry Coupled to the Skeletal Muscle Ryanodine Receptor". The Journal of Biological Chemistry 281 (44): 33477–86. doi:10.1074/jbc.M602306200. PMID 16945924.

[27] Sudo RT, Carmo, PL, Trachez MM, Pan Z, Zapata-Sudo G (2008). "Effects of Azumolene on Normal and Malignant Hyperthermia-Susceptible Skeletal Muscle". Basic & Clinical Pharmacology and Toxicology 102 (3): 308–16. doi:10.1111/j.1742-7843.2007.00156.x. PMID 18047479.

[Denborough_1962-28] Denborough MA, Forster JF, Lovell RR, Maplestone PA, Villiers JD (1962). "Anaesthetic deaths in a family". British Journal of Anaesthesia 34 (6): 395–6. doi:10.1093/bja/34.6.395. PMID 13885389. Historical account in Denborough MA (2008). "Malignant hyperthermia. 1962". Anesthesiology 108 (1): 156–7. doi:10.1097/01.anes.0000296107.23210.dd. PMID 18156894.

[29] Malcolm Whyte. 'Clinical Science in Canberra Hospital' in AJ Proust (ed) History of Medicine in Canberra and Queanbeyan and their Hospitals Brolga Press, Gundaroo p123 at 127

[30] Hall LW, Woolf N, Bradley JW, Jolly DW (1966). "Unusual reaction to suxamethonium chloride". Br Med J 2 (5525): 1305. doi:10.1136/bmj.2.5525.1305. PMC 1944316. PMID 5924819.

[Harrison-31] Harrison GG (January 1975). "Control of the malignant hyperpyrexic syndrome in MHS swine by dantrolene sodium". British Journal of Anaesthesia 47 (1): 62–5. doi:10.1093/bja/47.1.62. PMID 1148076. A reprint of the article, which became a "Citation Classic", is available in Br J Anaesth81 (4): 626–9. PMID 9924249 (free full text).

[32] Kolb ME, Horne ML, Martz R (1982). "Dantrolene in human malignant hyperthermia". Anesthesiology 56 (4): 254–62. doi:10.1097/00000542-198204000-00005. PMID 7039419.

Malignant hyperthermia
Classification and external resources
Abnormalities in the Ryanodine receptor 1 gene are commonly detected in malignant hyperthermia
ICD-10	T88.3
ICD-9	995.86
OMIM	145600 154275 154276 600467 601887 601888
DiseasesDB	7776
MedlinePlus	001315
MeSH	D008305
GeneReviews	Malignant Hyperthermia Susceptibility

匿名

検索

案内

malignant hyperthermia