CONTINUOUS MUSCLE FIBER ACTIVITY, HEREDITARY, INCLUDED
MYOKYMIA WITH PERIODIC ATAXIA MYOKYMIA 1, INCLUDED
ATAXIA, EPISODIC, WITH MYOKYMIA
MYOKYMIA 1 WITH OR WITHOUT HYPOMAGNESEMIA, INCLUDED
PAROXYSMAL ATAXIA WITH NEUROMYOTONIA, HEREDITARY
ISAACS-MERTENS SYNDROME, INCLUDED
EA1
AEM
EAM
AEMK
episodic ataxia with myokymia
Episodic ataxia is a neurologic condition characterized by spells of incoordination and imbalance, often associated with progressive ataxia (Jen et al., 2007).
- Genetic Heterogeneity of Episodic Ataxia
Episodic ataxia is a genetically heterogeneous ... Episodic ataxia is a neurologic condition characterized by spells of incoordination and imbalance, often associated with progressive ataxia (Jen et al., 2007). - Genetic Heterogeneity of Episodic Ataxia Episodic ataxia is a genetically heterogeneous disorder. See also EA2 (108500), caused by mutation in the CACNA1A gene (601011) on chromosome 19p13; EA3 (606554), which has been mapped to chromosome 1q42; EA4 (606552); EA5, caused by mutation in the CACNB4 gene (601949) on chromosome 2q22-q23; EA6 (612656), caused by mutation in the SLC1A3 gene (600111) on chromosome 5p13, and EA7 (611907), which has been mapped to chromosome 19q13. Isolated myokymia-2 (see 121200) is associated with mutation in the KCNQ2 gene (602235).
Van Dyke et al. (1975) described a kindred in which 11 persons in 3 consecutive generations had continuous muscle movement (myokymia) and periodic ataxia. Only 2 of the 11 affected were male and no male-to-male transmission was noted. ... Van Dyke et al. (1975) described a kindred in which 11 persons in 3 consecutive generations had continuous muscle movement (myokymia) and periodic ataxia. Only 2 of the 11 affected were male and no male-to-male transmission was noted. Indeed, neither affected male had children. The disorder presented in early childhood with attacks of ataxia of 1 to 2 minutes in duration, with associated jerking movements of the head, arms, and legs. Attacks were provoked by abrupt postural change, emotional stimulus, and caloric-vestibular stimulation. Myokymia of the face and limbs began at about age 12 years. Physical findings included large calves, normal muscle strength, and widespread myokymia of face, hands, arms, and legs, with a hand posture resembling carpopedal spasm. EMG at rest showed continuous spontaneous activity. Gastrocnemius biopsy showed changes consistent with denervation, as well as enlargement of muscle fibers. The same disorder was reported in 2 other families (Hanson et al., 1977; Gancher and Nutt, 1986). Brunt and van Weerden (1990) described a large family with paroxysmal ataxia and continuous myokymic discharges. There was at least 1 instance of male-to-male transmission. Often a postural tremor of the head and hands and fine twitching in the face and hand muscles were present. The attacks, which usually lasted a few minutes, might occur several times a day. They first appeared in childhood and tended to abate after early adulthood. The attacks were frequently precipitated by kinesigenic stimuli similar to the phenomenon observed in paroxysmal kinesigenic choreoathetosis (128200). In about half the adults, fine rippling myokymia could be detected on close inspection; in a few, it was obvious. Brunt and van Weerden (1990) concluded that the myokymic activity resulted from multiple impulse generation in peripheral nerves. Vaamonde et al. (1991) described the disorder in a 26-year-old woman who had had episodic unsteadiness lasting for a few minutes since the age of 6 years. The mother and 1 sister were identically affected. Electromyographic studies revealed myokymia (neuromyotonia). Phenytoin produced good control of the symptoms but acetazolamide was ineffective. Lubbers et al. (1995) studied 6 affected individuals in a 4-generation pedigree in which paroxysmal ataxia and myokymia were linked to markers on chromosome 12p in affected individuals who demonstrated kinesigenic provocation, attacks being brought on by repeat knee bends or sudden rising from a chair. Myokymic discharges were invariably demonstrable electromyographically, although not all affected members showed clinical myokymia. One affected family member also had attacks of paroxysmal kinesigenic choreoathetosis (see 601042 for kinesigenic choreoathetosis that has been mapped to chromosome 1p). Members of Lubbers' kindred responded to low doses of acetazolamide, although there was some loss of efficacy after prolonged treatment. Graves et al. (2010) reported 2 unrelated sets of monozygotic twins with genetically confirmed EA1 who showed remarkably different phenotypes. In the first family, twin sisters had onset of symptoms at ages 14 and 16 years, respectively. One sister had daily episodes lasting from 10 to 15 minutes and required maintenance on carbamazepine, whereas her twin had a less severe phenotype with weekly episodes lasting 5 to 10 minutes and did not require medication. Both had dizziness, slurred speech, and incoordination of the hands during attacks, but the more severely affected sister also had unsteady gait, weakness, and myokymia. In the second family, 1 twin brother had onset at age 1 year of weekly episodes lasting seconds to 10 minutes; medication was not required. His twin brother had onset at age 6 years of daily episodes lasting seconds to 3 minutes; carbamazepine was not effective. The attacks in both brothers were characterized by imbalance, weakness, blurred vision, slurred speech, myokymia, and incoordination of the hands. These symptoms were less severe in the first brother, although he had associated vertigo, headache, and nausea. Their affected mother had a progressive interictal cerebellar syndrome with ataxia and dysarthria. The report indicated that nongenetic factors play a role in the severity of EA1. - Isolated Myokymia Isolated spontaneous muscle twitches occur in many persons and have no grave significance. Wieczorek and Greger (1962) described a dominant pedigree with myokymia. Sheaff (1952) observed myokymia in a man and his 4 sons. In a portion of muscle removed for biopsy, fasciculations persisted for 8 minutes. Affected persons probably have an increased frequency of muscle cramps ('night cramps'). A syndrome of continuous muscle fiber activity was described by Ashizawa et al. (1983). Cerebrospinal fluid levels of homovanillic acid and 5-hydroxyindoleacetic acid were increased in the proband. Referred to as continuous motor neuron discharge, the disorder was present in 7 members of 3 generations. McGuire et al. (1984) described the syndrome of continuous muscle fiber activity in a 3-year-old boy and his 28-year-old mother. The boy had shown persistent fisting from the age of 4 months. Previously the family had observed diminished spontaneous motor activity with flexion contractures of the lower limbs. Cardiopulmonary studies, prompted by recurrent episodes of peripheral cyanosis, showed eventration of both diaphragms with poor motion. Increased muscle tone and stiffness persisted during sleep. EMG showed continuous motor unit activity which continued despite peripheral nerve blockade or general anesthesia. Phenytoin sodium effected 'considerable improvement.' The cyanotic episodes disappeared after plication of the diaphragms and phenytoin therapy. The mother had demonstrated persistent stiffness and fisting in early childhood. No form of medication was beneficial until phenytoin was given at age 8 for suspected seizures. She was still taking phenytoin at age 28 and showed toxic effects with a serum level of 36 mg/L. With decreased dosage, serpentine movements of the fingers and lower eyelids appeared. After discontinuation of phenytoin, myokymia continued in sleep and transient stiffness developed after initiation of movements. Chen et al. (2007) reported a family in which a mother and 3 sons had isolated myokymia without epilepsy or episodic ataxia. The proband was a 13-year-old boy who was diagnosed with cerebral palsy due to leg stiffness and showed delayed walking at age 18 months. At age 4 years, he was hospitalized with increasing leg pain, stiffness, and inability to walk during a flu-like illness. Serum creatine kinase was elevated during the acute attack. Examination showed periorbital myokymia, spastic gait, hyperreflexia, and extensor plantar responses. EMG studies showed continuous motor unit discharges. His mother and 2 affected brothers showed a similar phenotype; 3 of the patients also had esotropia. The 3 brothers were asymptomatic with carbamazepine treatment. Genetic studies identified a heterozygous mutation in the KCNA1 gene (176260.0014) that segregated with the disorder. Chen et al. (2007) noted that patients in this family showed unusual features, such as extensor plantar responses suggestive of corticospinal tract involvement and worsening of symptoms with febrile illness or anesthesia. - Association With Hypomagnesemia Glaudemans et al. (2009) studied a large 5-generation Brazilian family segregating autosomal dominant hypomagnesemia, in which 21 of 46 family members were affected. Beginning in infancy, the proband had recurrent muscle cramps, tetanic episodes, tremor, and muscle weakness, especially in the distal limbs. The proband reported several episodes during which she was 'not able to walk straight,' but no objective clinical signs of cerebellar dysfunction were apparent on examination; cerebral MRI showed slight atrophy of the cerebellar vermis. A younger brother had died in infancy from a severe attack of cramps and tetany, during which time his serum magnesium was as low as 0.28 mmol/l. Serum electrolyte levels measured during severe episodes of cramps and tetany in 2 affected family members revealed low serum magnesium with normal calcium and potassium concentrations; urinary magnesium excretion was normal, suggesting impaired tubular magnesium reabsorption, and urinary calcium excretion was normal. During the course of the study, the proband was hospitalized due to a sudden episode of facial myokymia, tremor, severe muscle spasms, muscular pain, cramps, muscular weakness, and intermittent tetanic contraction, all of which improved shortly after intravenous magnesium administration. Electromyographs of some affected family members showed myokymic discharge.
Browne et al. (1994) demonstrated mutations in the KCNA1 gene in 4 families with AEMK (176260.0001-176260.0004). A different missense point mutation was present in heterozygous state in each. All affected individuals are heterozygous.
In 2 families ... Browne et al. (1994) demonstrated mutations in the KCNA1 gene in 4 families with AEMK (176260.0001-176260.0004). A different missense point mutation was present in heterozygous state in each. All affected individuals are heterozygous. In 2 families with myokymia without ataxic episodes, Eunson et al. (2000) identified mutations in the KCNA1 gene (176260.0010-176260.0011). One of these families also segregated seizures. In a 5-generation Brazilian family segregating autosomal dominant hypomagnesemia and myokymia mapping to chromosome 12q, Glaudemans et al. (2009) identified a heterozygous missense mutation in the KCNA1 gene (N255D; 176250.0015) that segregated with the disease and was not found in 100 control chromosomes. For a comprehensive review of episodic ataxia type 1 and its causative mutations, see Brandt and Strupp (1997). Jen et al. (2007) provided a detailed review of the pathophysiology and molecular genetics of known episodic ataxia syndromes.
Episodic ataxia type 1 (EA1), a neurologic disease resulting from alterations in the voltage-gated potassium channel (Kv1.1), is suspected in individuals with the following clinical findings:...
DiagnosisClinical Diagnosis Episodic ataxia type 1 (EA1), a neurologic disease resulting from alterations in the voltage-gated potassium channel (Kv1.1), is suspected in individuals with the following clinical findings:Attacks of: generalized ataxia with jerking movements of head, arms, and legs; stiffening of the body; loss of balance; dizziness; blurred vision; dysarthria; and diplopia. These episodes may occur several times a month, may last seconds to minutes, and can be precipitated by anxiety, emotional stress, fatigue, startle response, and sudden postural changes (kinesigenic stimulation). Mild exercise, kinesigenic stimulation, and vestibular caloric stimulation may be used to induce attacks. Neuromyotonia (muscle cramps and stiffness) and myokymia (muscle twitching with a rippling appearance) may occur in the limbs or especially in the muscles of the face or the hands. Evidence of myokymia, detected by electromyography (EMG), is found in nearly all individuals with EA1 regardless of clinical findings. The EMG displays a pattern of either rhythmically or arrhythmically occurring singlets, duplets, or multiplets. Note: In some individuals myokymic activity on the EMG becomes apparent after the application of regional ischemia. Childhood or early-adolescent disease onset Family history consistent with autosomal dominant inheritanceTestingAxonal superexcitability and threshold electrotonus may be investigated by means of a simple and rapid electrophysiologic test that can differentiate individuals with EA1 from normal controls with high sensitivity and specificity [Tomlinson et al 2010].Brain MRI and routine laboratory blood tests, including serum concentration of creatine kinase and electrolytes, are generally normal.Muscle biopsy is usually not helpful in establishing the diagnosis, although bilateral calf hypertrophy, enlargement of type 1 and type 2 gastrocnemius muscle fibers, and variable glycogen depletion have been reported [Van Dyke et al 1975, Kinali et al 2004, Demos et al 2009]. Nevertheless, these changes have not been consistently reported among individuals with EA1.Molecular Genetic Testing Gene.KCNA1 is the only gene in which mutations are known to cause episodic ataxia type 1.Clinical testingTable 1. Summary of Molecular Genetic Testing Used in Episodic Ataxia Type 1View in own windowGene SymbolTest MethodMutations DetectedMutation Detection Frequency by Test Method 1Test AvailabilityKCNA1Sequence analysisSequence variants 2>90% 3ClinicalDeletion / duplication analysisDeletions / duplications 4Unknown; none reported 51. The ability of the test method used to detect a mutation that is present in the indicated gene2. Examples of mutations detected by sequence analysis may include small intragenic deletions/insertions and missense, nonsense, and splice site mutations; typically, exonic or whole gene deletions/duplications are not detected.3. All affected individuals described thus far are heterozygous for KCNA1 mutations at amino acid residues highly conserved among the voltage-dependent K+ channel superfamily. 4. Testing that identifies deletions/duplications not readily detectable by sequence analysis of the coding and flanking intronic regions of genomic DNA; included in the variety of methods that may be used are: quantitative PCR, long-range PCR, multiplex ligation-dependent probe amplification (MLPA), and chromosomal microarray (CMA) that includes this gene/chromosome segment.5. No deletions or duplications involving KCNA1 have been reported to cause episodic ataxia type 1.Interpretation of test results For issues to consider in interpretation of sequence analysis results, click here.For KCNA1 sequence variants, publications on in vitro assessment of channel function may be useful [Imbrici et al 2008]. Channel function assays are not offered on a clinical testing basis. Information on specific allelic variants may be available in Molecular Genetics (see Table A. Genes and Databases and/or Pathologic allelic variants).Testing Strategy To confirm/establish the diagnosis in a probandTo induce attacks:Mild exercise (knee bends; running up a staircase quickly; arising from a chair quickly) Vestibular stimulation (head turning from side to side while standing still; sitting still on a rotating chair; instillation of cold water (i.e., ≤30° C) into either external auditory canal) Sudden and unexpected tactile or acoustic stimuli causing a startle response (rising quickly after a loud handclap) To evaluate for interictal motor activity (neuromyotonia/myokymia) in individuals who report characteristic episodes: surface or needle EMG recordings are performed before, during, and after the application of regional ischemia (e.g., using an inflated sphygmomanometer cuff applied around the upper or lower arm for up to 15 minutes).Usually, sequence analysis of KCNA1 is recommended as a confirmatory diagnostic test.Although no deletions of KCNA1 have been reported to cause EA1, it is theoretically possible that such mutations exist. Therefore, deletion/duplication analysis may be useful in individuals displaying EA1 symptoms if sequence analysis does not identify a disease-causing KCNA1 mutation.Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require prior identification of the disease-causing mutation in the family. Genetically Related (Allelic) DisordersEunson et al [2000] reported a unique phenotype characterized by isolated neuromyotonia without episodes of ataxia in association with a mutation in KCNA1. It is unclear whether this truly represents a unique phenotype or falls within the phenotypic spectrum of episodic ataxia type 1.Hypomagnesemia with accompanying recurrent muscle cramps, tetanic episodes, tremor, and limb muscle weakness has been described in a large Brazilian family harboring a KCNA1 mutation [Glaudemans et al 2009].
Episodic ataxia type 1 (EA1), first described in 1975 by Van Dyke et al, is a potassium channelopathy characterized by constant myokymia and dramatic episodes of spastic contractions of the skeletal muscles of the head, arms, and legs with loss of both motor coordination and balance. During attacks some individuals may experience vertigo, blurred vision, diplopia, nausea, headache, diaphoresis, clumsiness, stiffening of the body, dysarthric speech, and difficulty in breathing [Van Dyke et al1975]. ...
Natural History Episodic ataxia type 1 (EA1), first described in 1975 by Van Dyke et al, is a potassium channelopathy characterized by constant myokymia and dramatic episodes of spastic contractions of the skeletal muscles of the head, arms, and legs with loss of both motor coordination and balance. During attacks some individuals may experience vertigo, blurred vision, diplopia, nausea, headache, diaphoresis, clumsiness, stiffening of the body, dysarthric speech, and difficulty in breathing [Van Dyke et al1975]. The duration of the attacks is brief, lasting seconds to minutes, although prolonged attacks of five to 12 hours have been described [Lee et al 2004a]. Some individuals experience severe ataxia more than 15 times per day, whereas others experience attacks less often than once a month [Van Dyke et al 1975]. The first symptoms typically manifest during childhood (1st or 2nd decade of life). A specific traumatic physical or emotional event may determine the onset and worsening of the disease [Imbrici et al 2008]. Attacks may be brought on by stimuli including fever, startle response, abrupt movements, emotional stress, anxiety, repeat knee bends, exercise, ingestion of caffeine, and riding a merry-go-round. Attacks may occur, for example, when the individual has had to suddenly alter course to avoid falling or potential collision. High temperatures that occur after a hot bath or during use of a hairdryer may also precipitate attacks [Eunson et al 2000]. Whether interictal ataxia develops in individuals with EA1 has not been clearly reported to date.Myokymia manifests clinically during and between attacks as fine twitching of groups of muscles and intermittent cramps and stiffness. Usually, it is evident as a fine rippling in perioral or periorbital muscles and by lateral finger movements when the hands are held in a relaxed, prone position. Rarely, episodes of intense myokymic activity during attacks without either ataxia or other neurologic deficits are observed. Myokymic activity is continuous.The exposure of the forearm to warm or cold temperatures may increase or decrease, respectively, the spontaneous activity recorded from a hand muscle. The severity of some symptoms may either improve or worsen with age [Imbrici et al 2008].Since the first description of EA1 by Van Dyke et al [1975] and the identification and characterization of mutations in KCNA1, the phenotypic spectrum of EA1 has widened considerably, indicating that it is not a purely cerebellar syndrome. Affected individuals may display delayed motor development, choreoathetosis, carpal spasm, clenching of the fists, and isolated neuromyotonia. Cognitive dysfunction described in EA1 includes severe receptive and expressive language delay; inability to learn to ride a bicycle; and the need for life-skill programs or schools for children with mild to moderate learning difficulties [Zuberi et al 1999, Demos et al 2009].Moderate muscle hypertrophy with generalized increase in muscle tone and bilateral calf hypertrophy are observed. Neuromuscular findings secondary to the increased tone include unusual hypercontracted posture; abdominal wall muscle contraction; elbow, hip, and knee contractures; and shortened Achilles tendons that may result in tiptoe walking. Some individuals display attacks of difficulty in breathing, which can occur during ataxic episodes or as isolated episodes of an inability to inhale without wheezing [Shook et al 2008].Skeletal deformities including scoliosis, kyphoscoliosis, high-arched palate, and minor craniofacial dysmorphism have been described [Kinali et al 2004, Klein et al 2004]. It is now apparent that phenotypic differences exist not only between families, but also between individuals of the same family. Tonic-clonic and partial seizures, an isolated episode consisting of photo-sensitive epilepsy [Imbrici et al 2008], as well as head-turning and eyes deviating to the same side, flickering eyelids, lip-smacking, apnea, and cyanosis have been reported [Zuberi et al 1999]. Abnormal electroencephalograms (EEG) have been observed in persons with EA1 [Van Dyke et al 1975, Zuberi et al 1999, Lee et al 2004a]. EEG may be characterized by intermittent and generalized slow activity, frequently intermingled with spikes. Zuberi et al [1999] described a three-year-old boy who presented with an ictal EEG with rhythmic slow-wave activity over the right hemisphere, becoming spike-and-wave complexes that subsequently spread to the left hemisphere. Neuromimaging with MRI is usually normal; however, Demos et al [2009] reported a family with cerebellar atrophy.
Due to significant interfamilial and intrafamilial phenotypic variability, reliable genotype-phenotype correlations have been extremely difficult to establish. Indeed, differences in severity and frequency of EA1 attacks have been reported even in monozygotic twins [Graves et al 2010]. ...
Genotype-Phenotype Correlations Due to significant interfamilial and intrafamilial phenotypic variability, reliable genotype-phenotype correlations have been extremely difficult to establish. Indeed, differences in severity and frequency of EA1 attacks have been reported even in monozygotic twins [Graves et al 2010].
Differential DiagnosisTable 2. Episodic Ataxia: OMIM Phenotypic SeriesView in own windowPhenotypePhenotype MIM numberGene/LocusGene/Locus MIM numberEpisodic ataxia/myokymia syndrome 160120 KCNA1, AEMK, EA1 176260 Episodic ataxia, type 2 108500 CACNA1A, CACNL1A4, SCA6 601011 Episodic ataxia, type 3 606554 EA3 606554 Episodic ataxia, type 4 606552 EA4, PATX 606552 Episodic ataxia, type 5 613855 CACNB4, EJM6, EA5, EIG9 601949 Episodic ataxia, type 6 612656 SLC1A3, EAAT1, EA6 600111 Episodic ataxia, type 7 611907 EA7 611907 Data from Online Mendelian Inheritance in ManEpisodic ataxia can occur sporadically or in a number of hereditary disorders:Episodic ataxia type 2 (EA2) is characterized by paroxysmal attacks of ataxia, vertigo, and nausea typically lasting minutes to days in duration. Stress, exertion, caffeine, and alcohol may trigger attacks that can be associated with dysarthria, diplopia, tinnitus, dystonia, hemiplegia, and headache. Approximately 50% of individuals with EA2 have migraine headaches. Onset is typically in childhood or early adolescence. MRI can demonstrate atrophy of the cerebellar vermis. EA2 is inherited in an autosomal dominant manner. Mutations in CACNA1A, which encodes for a voltage-dependent Ca2+ channel alpha subunit, can cause this disease.Episodic ataxia type 3 (EA3) [OMIM 606554] has been described in two families of northern European origin from rural North Carolina by Farmer & Mustian [1963] and Vance et al [1984]. A relationship between the two kindreds is suspected but has not been established. EA3 is characterized by attacks of vertigo, diplopia, and ataxia beginning in early adulthood. In some individuals, slowly progressive cerebellar ataxia occurs. This condition does not link to loci identified with EA1, EA2, or spinocerebellar ataxia types 1, 2, 3, 4, and 5 [Damji et al 1996]. A candidate region on chromosome 1q42 has been identified [Cader et al 2005]. Episodic ataxia type 4 (EA4) [OMIM 606552] has been described in a large Canadian Mennonite family [Steckley et al 2001]. EA4 is also known as familial periodic vestibulocerebellar ataxia and is characterized by brief acetazolamide-responsive attacks of vestibular ataxia, vertigo, tinnitus, and interictal myokymia. Interictal nystagmus and ataxia were not identified. The age of onset is variable. The gene defect that underlies EA4 is not known; EA4 does not link to the loci for EA1 or EA2.Episodic ataxia type 5 (EA5) [OMIM 601949] can result from a mutation in CACNB4, encoding the beta-4 isoform of the regulatory beta subunit of voltage-activated Ca(2+) channels. A c.311G>T (p.Cys104Phe; reference sequences NM_000726.3; NP_000717.2) mutation has been described in a French-Canadian family [Escayg et al 2000]. The phenotype was characterized by recurrent episodes of vertigo and ataxia that lasted for several hours. Interictal examination showed spontaneous downbeat and gaze-evoked nystagmus and mild dysarthria and truncal ataxia. Acetazolamide prevented the attacks. EA5 is allelic with juvenile myoclonic epilepsy (JME); the semiology of seizures in EA5 is similar to JME.Episodic ataxia type 6 (EA6) [OMIM 612656] is characterized by attacks of ataxia precipitated by fever, subclinical seizures, slurred speech followed by headache, and bouts of arm jerking with concomitant confusion and alternating hemiplegia. EA6 can result from mutations in SLC1A3, which encodes the excitatory amino acid transporter 1 (EAAT1). In cells expressing mutated proteins, glutamate uptake is reduced, suggesting that glutamate transporter dysfunction underlies the disease [Jen et al 2005, de Vries et al 2009].Episodic ataxia type 7 (EA7) [OMIM 611907] has been described in a four-generation family whose affected individuals showed episodic ataxia before age 20 years [Kerber et al 2007]. The disease is characterized by attacks associated with weakness, vertigo, and dysarthria lasting hours to days. Attacks may be brought about by exercise and excitement. A candidate region on chromosome 19q13, termed the EA7 locus, has been identified [Kerber et al 2007]. Autosomal dominant spastic ataxia (ADSA) [OMIM 108600]. Affected individuals initially show progressive leg spasticity of variable degree followed by ataxia in the form of involuntary head jerk, dysarthria, dysphagia, and ocular movement abnormalities. The age at onset is from early childhood to early twenties. Linkage studies identified a locus on 12p13, termed SAX1 [Meijer et al 2002].Familial paroxysmal kinesigenic dyskinesia (PKD) is characterized by attacks of dystonia, choreoathetosis, and ballism that last seconds to hours and are sometimes preceded by an aura and precipitated by sudden movements, cold, hyperventilation, and mental tension. Attacks can be as frequent as 100 per day to as few as one per month. Age of onset is typically in childhood [Bruno et al 2004]. Familial PKD is inherited in an autosomal dominant manner; the gene(s) associated with PKD have not been identified. Linkage of familial PKD to 16q11.2-q22.1 has been established in several families with PKD [Tomita et al 1999, Bennett et al 2000, Valente et al 2000]. Familial paroxysmal nonkinesigenic dyskinesia (PNKD) is characterized by attacks of dystonia, chorea, ballismus, or athetosis provoked by alcohol, caffeine, excitement, stress, or fatigue. Attacks are not typically triggered by movement, may be accompanied by a preceding aura, last minutes to hours, and rarely occur more than once per day. Age of onset is typically in childhood or early teens. Familial PNKD is inherited in an autosomal dominant manner; PNKD, encoding myofibrillogenesis regulator 1, is the only gene known to be associated with this disease [Lee et al 2004b, Rainier et al 2004, Chen et al 2005a]. A second locus for familial PNKD has been identified on chromosome 2q31 in a Canadian family of European descent [Spacey et al 2006].Isaacs syndrome (acquired neuromyotonia, NMT) is a rare neuromuscular disorder characterized by hyperexcitability of the motor nerve that results in continuously contracting or twitching muscles (myokymia) and muscle hypertrophy. Individuals also experience cramping, increased sweating, and delayed muscle relaxation. Stiffness is most prominent in limb and trunk muscles. Symptoms are not usually triggered by exercise and occur even during sleep or when individuals are under general anesthesia. A few affected individuals report sleep disorders, anxiety, and memory loss (Morvan syndrome). Onset is between ages 15 and 60 years. The acquired form occasionally develops in association with peripheral neuropathies or after radiation treatment. Twenty percent of affected individuals have an associated thymoma. Antibodies to voltage-gated potassium channels are detected in approximately 40% of affected individuals [Hart et al 2002]. It has been shown that antibodies bind variably to the Kv1.1- and 1.2-containing juxtaparanodes of peripheral and central myelinated axons [Kleopa et al 2006].Note to clinicians: For a patient-specific ‘simultaneous consult’ related to this disorder, go to , an interactive diagnostic decision support software tool that provides differential diagnoses based on patient findings (registration or institutional access required).
To establish the extent of disease in an individual diagnosed with episodic ataxia type 1, the following evaluations are recommended:...
ManagementEvaluations Following Initial Diagnosis To establish the extent of disease in an individual diagnosed with episodic ataxia type 1, the following evaluations are recommended:Detailed medical history of the individual Neurologic examination Initiation (and observation) of attacks of ataxia by either mild exercise or vestibular stimuli EMG to confirm the presence of myokymia, particularly if it is not visible on examination EEG to look for epilepsy [Zuberi et al 1999, Eunson et al 2000, Chen et al 2007]Medical genetics consultationTreatment of ManifestationsAcetazolamide (ACTZ), a carbonic-anhydrase (CA) inhibitor, may reduce the frequency and severity of the attacks in some but not all affected individuals. The mechanism by which ACTZ reduces the frequency and severity of the attacks is unclear. The recommended starting dosage is 125 mg once a day, given orally. However, individuals with good renal function may require higher daily doses, ranging from 8 to 30 mg/kg/day in one to four divided doses (not to exceed 1 g/day). ACTZ should not be prescribed to individuals with liver, renal, or adrenal insufficiency.Chronic treatment with ACTZ may result in side effects including paresthesias, rash, and formation of renal calculi. Antiepileptic drugs (AEDs) may significantly reduce the frequency of the attacks in responsive individuals; however, the response is heterogeneous as some individuals are particularly resistant to drugs [Eunson et al 2000].Diphenylhydantoin treatment at a dose of 150-300 mg daily resulted in reasonable control of seizures in some individuals [Van Dyke et al 1975]. In particular, phenytoin treatment at a dose of 3.7 mg/kg/day may improve muscle stiffness and motor performance [Kinali et al 2004]. Nevertheless, phenytoin should be used with caution in young individuals, as it may cause permanent cerebellar dysfunction and atrophy [De Marco et al 2003]. Sulthiame 50-200 mg daily may reduce the attack rate. During this treatment abortive attacks were still noticed lasting a few seconds and troublesome side effects were paresthesias and intermittent carpal spasm. Carbamazepine up to 1600 mg daily [Eunson et al 2000]. However, the dose needs to be adjusted according to different factors including, age, weight, the particular carbamazepine product being used, responsiveness of the individual, and other medications being taken. Prevention of Primary ManifestationsIn addition to the pharmacologic treatments mentioned above behavioral measures, such as avoidance of stress, abrupt movements, loud noises or caffeine intake may be used to reduce disease manifestations in either a symptomatic or an asymptomatic person. Prevention of Secondary ComplicationsContractures occur in a small proportion of individuals and can be prevented by appropriate physiotherapy.SurveillanceSurveillance should include annual neurologic examination.Agents/Circumstances to AvoidGeneral anesthetics have occasionally been reported to precipitate or aggravate neuromyotonia [Eunson et al 2000].Evaluation of Relatives at RiskSee Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.Pregnancy Management No published literature addresses management of the pregnancy of an affected mother or the effect of maternal EA1 on a fetus. However, the mother should be made aware that during attacks, loss of balance and falls could endanger the fetus’s life. Several stressors trigger attacks that may cause breathing difficulties, thus, delivery by C-section should be considered. Therapies Under InvestigationSearch ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.OtherMorphologic studies on lateral gastrocnemius (LG) muscles derived from a mouse model of EA1 did not reveal changes in muscle mass, fiber type composition, or vascularization [Brunetti et al 2012].Homozygous V408A/V408A mutations are embryonically lethal in an animal model of EA1 [Herson et al 2003], although this has not been reported in humans.
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED....
Molecular GeneticsInformation in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.Table A. Episodic Ataxia Type 1: Genes and DatabasesView in own windowGene SymbolChromosomal LocusProtein NameLocus SpecificHGMDKCNA112p13.32Potassium voltage-gated channel subfamily A member 1KCNA1 homepage - Mendelian genesKCNA1Data are compiled from the following standard references: gene symbol from HGNC; chromosomal locus, locus name, critical region, complementation group from OMIM; protein name from UniProt. For a description of databases (Locus Specific, HGMD) to which links are provided, click here.Table B. OMIM Entries for Episodic Ataxia Type 1 (View All in OMIM) View in own window 160120EPISODIC ATAXIA, TYPE 1; EA1 176260POTASSIUM CHANNEL, VOLTAGE-GATED, SHAKER-RELATED SUBFAMILY, MEMBER 1; KCNA1Molecular Genetic Pathogenesis Voltage-gated potassium channels (Kv) play key roles in neurotransmission and nerve cell physiology. Kv channels shorten the duration of action potentials, modulate the release of neurotransmitters, and control the excitability, electrical properties, and firing pattern of central and peripheral neurons [Hille 2001, Pessia 2004]. In particular, Kv1.1 channels (encoded by KCNA1) regulate neuromuscular transmission, control the release of β-aminobutyric acid (GABA) from cerebellar basket cells onto Purkinje cells [Herson et al 2003], and modulate synaptic transmission in hippocampus [Geiger & Jonas 2000]. Nomenclature of Kv channels is organized by subfamilies based on sequence relatedness by using the abbreviation Kvy.x whereby the prefix specifies both the permeating ion (K+) and the voltage-dependence of the channel (v). According to this standardized nomenclature Shaker-related channels have been classified in the subfamily Kv1.x and each member numbered Kv1.1 through Kv1.9. The same criteria have been used to classify auxiliary subunits (Kvβ1.1 and Kvβ1.2) and channels related to the subfamilies Shab (Kv2.1 and Kv2.2), Shaw (Kv3.1 to 3.4) and Shal (Kv4.1 to Kv4.3). Functional homomeric Kv1.1 channels are tetrameric structures composed of four identical monomers. Each monomer is encoded by KCNA1.However, potassium channel diversity is greatly enhanced by the ability of different types of pore-forming subunits to heteropolymerize and to form channels with properties different from the parental homomeric channels. Kv channels may exhibit fast N-type inactivation that is caused by a “ball-and-chain” mechanism of pore occlusion. Fast inactivation may be conferred to non-inactivating channels by auxiliary subunits such as Kvβ1.1 and Kvβ1.2. Four β subunits participate to the ion channel complex and provide four inactivation particles. Notable examples:Heteromeric channels composed of Kv1.1 and Kv1.2 that are expressed at cerebellar basket cell terminals and at the juxtaparanodal region of motor axonsChannels composed of Kv1.1, Kv1.4, and, Kvβ1.1 subunits that are expressed in hippocampal mossy fiber boutons Kv1.1 channels possess a slower process of inactivation, which has been named C-type or P-type depending on the structural determinants of this process that have been located within the C-terminus and pore region.D’Adamo et al first demonstrated that KCNA1 mutations associated with EA1 alter the expression and gating properties of heteromeric channels composed of human Kv1.2 and Kv1.1 subunits [D’Adamo et al 1999, Rea et al 2002]. Successively, it has been shown that KCNA1 mutations also impair the function of hetero-oligomeric complexes comprising Kv1.1, Kv1.4, and Kvβ1.x subunits in distinct ways [Imbrici et al 2006, Imbrici et al 2011]. These studies raised the question as to whether other allelic variations, whose gene products may or may not form hetero-oligomeric complexes with Kv1.1 subunits, may underlie a similar channelopathy.Normal allelic variants. KCNA1 has a transcript of 7983 nucleotides with a coding region of 1488. There are two exons, but the coding region is located entirely within exon 2. In 5% of control chromosomes analyzed by Zuberi et al [1999] two silent changes in the coding sequence were observed, c.684T>C and c.804G>C (see Table 3). The reference sequences in Table 3 include the correction of a sequence error published by Ramaswami et al [1990] and reported by Browne et al [1994] and Zuberi et al [1999]. Pathologic allelic variants. To date, 23 KCNA1 mutations have been identified by sequence analysis (see Figure 1). Most are missense mutations that are distributed throughout the gene; however, nonsense and small deletion mutations have also been identified [Eunson et al 2000, Shook et al 2008]. FigureFigure 1. Schematic drawing of the conventional membrane topology of a human Kv1.1 subunit. Four such subunits comprise a functional homotetrameric channel. Different subunits belonging to the Kv1 subfamily may form heterotetrameric channels. The positions (more...)Interestingly, four different mutations of the highly conserved threonine 226 residue, located within the second transmembrane segment, have been identified [Rajakulendran et al 2007]. In particular, the p.Thr226Arg mutation is associated with epilepsy, infantile contractures, postural abnormalities, and skeletal deformities. Although, the defects caused by the p.Thr226Ala, p.Thr226Arg, and p.Thr226Met mutations on channel functions are virtually identical, they lead to diverse phenotypes. Table 3. Selected KCNA1 Allelic Variants View in own windowClass of Variant AlleleDNA Nucleotide Change (Alias 1) Protein Amino Acid ChangeReference SequencesNormalc.684T>C (C684T)p.= 2NM_000217.2 NP_000208.2c.804G>C (C804G)p.= 2Pathologicc.676A>Gp.Thr226Alac.677C>Gp.Thr226Argc.677C>Tp.Thr226Metc.1222G>Tp.Val408Leuc.1241T>Gp.Phe414Cysc.1249C>Tp.Arg417*c.748_750delTTCp.Phe250delSee Quick Reference for an explanation of nomenclature. GeneReviews follows the standard naming conventions of the Human Genome Variation Society (www.hgvs.org). 1. Variant designation that does not conform to current naming conventions2. p.= designates that protein has not been analyzed, but no change is expected.Normal gene product. KCNA1 encodes the voltage-gated K+ channel Kv1.1. The predicted 496-amino acid Kv1.1 protein contains six hydrophobic segments with the N- and C-termini residing inside the cell. The S4 segment of each Kv1.1 subunit comprises the main voltage sensor that opens the channel by undergoing a conformational rearrangement upon membrane depolarization. The S5-S6 loop (H5 region) contributes to the ion-conducting pore. The GYG residues, residing within this loop, control the K+ selectivity of the channel (see also Molecular Genetic Pathogenesis). Abnormal gene product. The molecular mechanisms underlying episodic ataxia type 1 have been established by determining the functional properties of wild-type and several mutant channels in Xenopus oocytes or mammalian cell lines [Adelman et al 1995, D’Adamo et al 1998, Zerr et al 1998, D’Adamo et al 1999, Zuberi et al 1999, Eunson et al 2000, Manganas et al 2001, Imbrici et al 2003, Cusimano et al 2004, Imbrici et al 2006, Imbrici et al 2007, Imbrici et al 2008, Imbrici et al 2009, Imbrici et al 2011]. Overall, these studies have shown that allelic variations underlying EA1 impair channel function and reduce the outward K+ flux through the channel, although with highly variable effects on aspects of channel expression and gating. Regarding channel gating, KCNA1 mutations may alter the protein structure and affect the kinetics of opening and closing, voltage dependence, and N- and C-type inactivation [D’Adamo et al 1998, D’Adamo et al 1999, Maylie et al 2002, Imbrici et al 2006, Imbrici et al 2009, Imbrici et al 2011]. Individuals with EA1 are heterozygous for a KCNA1 disease-causing mutation, possessing a normal and a mutated allele, which may be equally expressed. Therefore, channels composed of wild-type and mutated subunits may be formed. Co-expression systems, which mimic the heterozygous condition, have shown that some mutant subunits exert dominant negative effects on wild-type subunits, resulting in less than half the normal current, whereas others have virtually no effect on surface expression. It has been shown that KCNA1 allelic variations also alter the function of heteromeric channels containing different subunits, demonstrating that mutations in a single gene disrupt the functions of other closely related proteins [D’Adamo et al 1999, Rea et al 2002, Imbrici et al 2006]. Based on these findings, a model accounting for the cerebellar symptoms of EA1 was proposed by D’Adamo and colleagues (see Figure 2).FigureFigure 2. Proposed effects of EA1-causing mutations on basket cell and Purkinje cell inhibitory outputs. The diagram shows a basket cell which has synapses on the initial segment and soma of a number of Purkinje cells from the cerebellar (more...)A mouse model of EA1 has been generated by introducing a mutation analogous to the human p.Val408Ala mutation into the murine ortholog, Kcna1. These animals showed impaired motor performance and altered cerebellar GABAergic transmission from the basket cells to the Purkinje cells [Herson et al 2003]. Such Kv1.1 knock-in ataxic mice also exhibited spontaneous myokymic activity exacerbated by fatigue, ischemia, and low temperature [Brunetti et al 2012]. Spontaneous myokymic discharges were present despite motor nerve axotomy, suggesting that the motor nerve is an important generator of myokymic activity. This study also showed that altered Ca2+ homeostasis in motor axons of mutant animals may contribute to spontaneous myokymic activity [Brunetti et al 2012]. The causes that trigger the paroxysms of ataxia remain elusive, although a phenomenon akin to spreading acidification of the cerebellar cortex has been suggested [Chen et al 2005b].