title: The changing face of malignant hyperthermia: less fulminant, more insidious..
abstract: Modern anaesthetic techniques have resulted in the clinical presentation of malignant hyperthermia to be more often indolent and/or insidious than truly fulminant, as previously known in the anaesthetic community. We present four recently referred cases to illustrate this point: one late-onset case, two patients with slowly progressive hypercapnia as the sole sign and a fourth patient with postoperative myalgias and elevated creatine kinase. We also discuss the reasons for the shift in typical clinical presentation. The more insidious character of malignant hyperthermia is most likely due to the lower triggering potency of modern volatile anaesthetics, the mitigating effects of several intravenous drugs (neuromuscular blocking agents, alpha 2 adrenergic receptor agonists, beta adrenergic blockade) or techniques (neuraxial anaesthesia) and the routine use of end-tidal CO2 monitoring leading to the early withdrawal of triggering drugs. Awareness among anaesthetists of this change in presentation is important since the clinical diagnosis is often more doubtful and, if corroborative evidence is not sought, the diagnosis may be delayed or missed altogether.
authors.affiliation: Consultant Anaesthetist, Department of Anaesthesiology, University Hospital Antwerp, Edegem, Belgium.
authors.forename: L
authors.initials: L
authors.lastname: Heytens
authors.affiliation: Anaesthetist, Department of Anaesthesiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
authors.forename: P
authors.initials: P
authors.lastname: Forget
authors.affiliation: Professor, Department of Anaesthesiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
authors.forename: J L
authors.initials: JL
authors.lastname: Scholtès
authors.affiliation: Professor and Paediatric Anaesthetist, Department of Anaesthesiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
authors.forename: F
authors.initials: F
authors.lastname: Veyckemans
mesh_terms: D000293:Adolescent; D000368:Aged; D000758:Anesthesia / Q000009:adverse effects*; D018685:Anesthetics, Inhalation / Q000009:adverse effects; D003402:Creatine Kinase / Q000097:blood; D006801:Humans; D006935:Hypercapnia / Q000097:blood / Q000209:etiology; D008297:Male; D008305:Malignant Hyperthermia / Q000097:blood / Q000150:complications / Q000175:diagnosis*; D008875:Middle Aged; D009467:Neuromuscular Depolarizing Agents / Q000009:adverse effects; D013390:Succinylcholine / Q000009:adverse effects
chemical_list: D018685:Anesthetics, Inhalation; D009467:Neuromuscular Depolarizing Agents; D003402:Creatine Kinase; D013390:Succinylcholine
keywords: anaesthetics volatile halogenated hydrocarbons; complications; genetic factors; hyperthermia; malignant hyperthermia; phenotype