Detection of LAMA2 c.715C>G:p.R239G mutation in a newborn with raised creatine kinase: A case report

BACKGROUND We report a rare case of primary clinical presentation featuring elevated creatine kinase(CK)levels in a neonate,which is associated with the LAMA2 gene.In this case,a heterozygous mutation in exon5 of the LAMA2 gene,c.715C>G(resulting in a change of nucleotide number 715 in the coding region from cytosine to gua-nine),induced an amino acid alteration p.R239G(No.239)in the patient,repre-senting a missense mutation.This observation may be elucidated by the neonatal creatine monitoring mechanism,a phenomenon not previously reported.CASE SUMMARY We analysed the case of a neonate presenting solely with elevated CK levels who was eventually discharged after supportive treatment.The chief complaint was identification of increased CK levels for 15 d and higher CK values for 1 d.Ad-mission occurred at 18 d of age,and despite prolonged treatment with creatine and vitamin C,the elevated CK levels showed limited improvement.Whole exo-me sequencing revealed the presence of a c.715C>G mutation in LAMA2 in the newborn,correlating with a clinical phenotype.However,the available informa-tion offers insufficient evidence for clinical pathogenicity.CONCLUSION Mutations in LAMA2 are associated with the clinical phenotype of increased neonatal CK levels,for which no specific treatment exists.Whole genome sequen-cing facilitates early diagnosis.

Creatine kinase in the diagnosis and prognostic prediction of amyotrophic lateral sclerosis:a retrospective case-control study

Creatine kinase is a muscle enzyme that has been reported at various levels in different studies involving patients with amyotrophic lateral sclerosis.In the present retrospective case-control study,we included 582 patients with amyotrophic lateral sclerosis and 582 age-and sexmatched healthy controls.All amyotrophic lateral sclerosis participants received treatment in the Department of Neurology,West China Hospital,China,between May 2008 and December 2018.Serum creatine kinase levels in patients with amyotrophic lateral sclerosis were significantly higher than those in healthy controls.Subgroup analysis revealed that serum creatine kinase levels in men were higher than those in women in both amyotrophic lateral sclerosis patients and healthy controls.Compared with patients with bulbar-onset amyotrophic lateral sclerosis,patients with limb-onset amyotrophic lateral sclerosis had higher creatine kinase levels.Spearman's correlation analysis revealed that serum creatine kinase levels were not correlated with body mass index,Amyotrophic lateral Sclerosis Functional Rating ScaleRevised score,or progression rate.After adjusting for prognostic covariates,higher log creatine kinase values were correlated with higher overall survival in the amyotrophic lateral sclerosis patients.We also investigated the longitudinal changes in serum creatine kinase levels in 81 amyotrophic lateral sclerosis patients;serum creatine kinase levels were decreased at the second blood test,which was sampled at least 6 months after the first blood test.Together,our results suggest that serum creatine kinase levels can be used as an independent factor for predicting the prognosis of amyotrophic lateral sclerosis patients.This study received ethical approval from the Ethics Committee of West China Hospital,China(approval No.2015(236))on December 23,2015.

Flunarizine and lamotrigine prophylaxis effects on neuron-specific enolase, S-100, and brain-specific creatine kinase in a fetal rat model of hypoxic-ischemic brain damage

BACKGROUND： Calcium antagonists may act as neuroprotectants, diminishing the influx of calcium ions through voltage-sensitive calcium channels. When administered prophylactically, they display neuroprotective effects against hypoxic-ischemic brain damage in newborn rats. OBJECTIVE： To investigate the neuroprotective effects of flunarizine （FNZ）, lamotrigine （LTG） and the combination of both drugs, on hypoxic-ischemic brain damage in fetal rats. DESIGN AND SETTING： This randomized, complete block design was performed at the Department of Pediatrics, Shenzhen Fourth People＇s Hospital, Guangdong Medical College. MATERIALS： Forty pregnant Wistar rats, at gestational day 20, were selected for the experiment and were randomly divided into FNZ, LTG, FNZ ＋ LTG, and model groups, with 10 rats in each group. METHODS： Rats in the FNZ, LTG, and FNZ ＋ LTG groups received intragastric injections of FNZ （0.5 mg/kg/d）, LTG （10 mg/kg/d）, and FNZ （0.5 mg/kg/d） ＋ LTG （10 mg/kg/d）, respectively. Drugs were administered once a day for 3 days prior to induction of hypoxia-ischemia. Rats in the model group were not administered any drugs. Three hours after the final administration, eight pregnant rats from each group underwent model establishment hypoxia-ischemia brain damage to the fetal rats. Cesareans were performed at 6, 12, 24, and 48 hours later; and 5 fetal rats were removed from each mother and kept warm. Two fetuses without model establishment were removed by planned cesarean at the same time and served as controls. A total of 0.3 mL serum was collected from fetal rats at 6, 12, 24, and 48 hours, respectively, following birth. MAIN OUTCOME MEASURES： Serum protein concentrations of neuron-specific enolase and S-100 were measured by ELISA. Serum concentrations of brain-specific creatine kinase were measured using an electrogenerated chemiluminescence method. RESULTS： Serum concentrations of neuron-specific enolase, S-100, and brain-specific creatine kinase were significantly higher in the hypoxic-ischemic fetal rats, compared with the non-hypoxic-ischemic group. Serum concentrations of neuron-specific enolase, S-100, and brain-specific creatine kinase were significantly less in the FNZ, LTG, and FNZ ＋ LTG groups following ischemia, compared with the model group （P 〈 0.01）. However, these values were significantly greater in the FNZ and LTG groups, compared with the FNZ ＋ LTG group, following ischemia （P 〈 0.01）. CONCLUSION： Preventive antenatal use of oral FNZ and LTG has positive neuroprotective effects on intrauterine hypoxic-ischemic brain damage. The combined effect of these two drugs is superior.

Oligosaccharide and Creatine Supplementation on Glucose and Urea Nitrogen in Blood and Serum Creatine Kinase in Basketball Athletes

Summary： The effects of oligosaccharide and creatine （Cr） supplementation on glucose, lactic acid and urea nitrogen levels in blood and activity of serum creatine kinase （CK） were explored. Twenty CUBA male athletes were divided into 4 groups： group A （supplementation of Cr alone）, group B （supplementation of oligosaccharide）, group C （supplementation of oligosaccharide and Cr） and group D （placebo control group）. By using orthogonal L4 table （2a ）, the experiment was performed. There were factors including oligosaccharide （carbohydrate, CHO）, Cr and their correlation. Each factor had two levels： supplementation and no-supplementation. The results showed that the supplementation of CliO or Cr alone, combined supplementation of CHO and Cr could significantly reduce the glucose, urea nitrogen levels in blood and serum CK activity after competition in the athletes. Moreover, the effects of combined supplementation of CHO and Cr were more satisfactory. It was concluded that supplementation of CliO and Cr could promote the recovery of physical performance and athletic abilities after athletics in basketball athletes.

RXPERIMENTAL AND CLINICAL STUDY OF CREATINE KINASE BB ACTIVITY FOR THE DIAGNOSIS ON BRAIN DAMAGE

Objective To study the differential diagnosis on cerebral concussion and mild cerebral contusion value of the brain type creatine kinase isoenzyme(CK BB),and evaluate the seriousness of brain damage and prognosis of the patients with acute head injury.Methods Chromatographic separating and fluorometric quantifying technique was used to detect the CK BB activity in the cerebrospinal fluid(CSF) of 117 patients with acute head injury and 12 patients with increased intracranial pressure and 20 normal people.Results The CSF CK BB activity of the patients with acute head injury was remarkably higher than that of the normal people and the CSF CK BB activity increased with the seriousness of brain damage.There was a close relationship between CSF CK BB activity and prognosis,and higher activity of CSF CK BB indicated poor prognosis.Conclusion CSF CK BB activity could be used as a new index to diagnose brain damage and evaluate the seriousness of brain damage and prognosis.

Relationship Between Serum Creatine Kinase Isoenzyme MM Subbands and the Gradation of Coronary Stenosis in Patients with Unstable Angina Pectoris

Objective To observe the relationship between serum creatine kinase isoenzyme MM sub-bands (CKMM3/MM1 ratio) and the gradation of coronary stenosis and provide a simple, reliable, and economical method for identifying high-risk unstable angina pectoris (UAP). Mehtods Blood samples were drawn at different time after onset of chest pain in 21 patients with UAP and only once in 20 each volunteers for control. CKMM3/MM1 ratio was detected by nonserial buffer agarose gel electrophoresis. CKMB and CK were observed by velocity method. An emergent coronary arteriography was performed as soon as patients were admitted into hospital. Results Patients with UAP were divided into two subgroups: patients with elevated serum enzyme [P( + )] and patients with normal serum enzyme [P( - ) ] according to CKMM3/MM1 ratio < 0. 5. Patients with UAP( + ) had higher serum CKMM3/MM1 ratios from 0.5 to 12hrs and serum CKMB from 2 to 12 hrs than those with UAP( - ) and control ( P < 0. 05) . Serum enzyme concentrations of patients with UAP whose coronary lumen had 90% or more than 90% stenosis were significantly higher than those whose coronary lumen had less than 90% stenosis ( P <0. 01) . Any CK-MM3/MM1 ratio was less than 1. 0 and CK within the normal range in patients with UAP( + ) group. Conclusions CKMM3/MM1 ratios in patients with UAP can reflect severity of myocardial ischemia. SerumCKMM3/MM1 ratio provides a simple, reliable, and economical method for identifying high-risk UAP.

RELATIONS OF INTRACRANIAL PRESSURE, CREATINE KINASE AND BRAINSTEM AUDITORY EVOKED POTENTIAL IN PATIENTS WITH TRAUMATIC BRAIN EDEMA

We studied the relations of intracranial pressure (ICP),creatine kinase (CK) and bralnstem auditory evoked potential (BAEP) in 44 patients with traumatic brain edema who were admitted to our hospital from June 1990 to February 1991. There were 30 males and 14 females, with age range from 9 to 67 years. The results showed that the abnormal BAEP could reflect the severity of cerebral edema in acute head injury and was related to ICP and serum CK levels. When ICP>30 mmHg (4kPa), the abnormality of BAEP was more obvious than that of the control group (P<0.05); the serum CK levels were also elevated markedly. In patients with ICP over and below 4kPa, the rate of abnormal BAEP was 38.46% and 77.78% respectively (P<0.05). The serum CK level in the normal group or in the group with moderate abnormality of BAEP was significantly different from that in the group with severe abnormality or lack of BAEP (274.8± 98.24 U/L vs 705.3± 364.27 U/L; P<0.001). After treatment, the ICP returned to normal, and the BAEP norm

Studies on the creatine kinase MM isoforms of normal and Duchenne muscular dystrophic patients

OBJECTIVE: To study the changes of creatine kinase MM (CK-MM) isoforms in Duchenne muscular dystrophy (DMD) patients. METHODS: Serum samples from 49 DMD patients and 40 control subjects were collected for CK-MM isoforms measurement. CK-MM isoforms were separated within 30 minutes by electrophoresis on agarose gel with a discontinuous buffer system at constant current of 30 mA and low voltage of 200-300 V, then measured by fluorescence scanning. RESULTS: Significant differences of MM2/MM1 ratio were found between DMD patients and control subjects (P

Amplified fluorescence of Mg^2+ selective red-light emitting carbon dot in water and direct evaluation of creatine kinase activity

Carbon quantum dot/carbon dot(CD)exhibiting sustained photoluminescence at longer wavelengths in aqueous solution is difficult to prepare,but has enormous potential in biomedical applications.For the first time,we report the magnesium(II)selective fluorescence enhancement of a red-light emitting anthrarufin and boric acid-derived CD in aqueous solution for direct evaluation of creatine kinase(CK)enzyme activity.The CD displayed visually detectable,intense red fluorescence only in the presence of magnesium ion(Mg^2+)at physiological pH value when irradiated with an ultraviolet(UV)source.Concurrently,a significant increase in steady-state fluorescence intensity and fluorescence lifetime was documented.A time-dependent density functional theory(TD-DFT)analysis displayed a bathochromic shift in UV–visible(vis)absorption,and increased oscillator strength of transition resulting from the selective chelation of Mg^2+withβ-hydroxy keto functionality on the surface of the CD.The CD–Mg^2+assembly was subsequently used to conceptualize the detection of CK directly through the exploration of the differential binding affinity of Mg2+with adenosine triphosphate(ATP),adenosine diphophate(ADP),and CD that is otherwise not possible with commercially available kits as of today.Thus,the report delineated here usher grandeur potential of CD for biological explorations related to Mg2+or ATP sensing and monitoring of Mg^2+-dependent enzymatic activity through a clear understanding of the chemistry.

Effects of Glycerol in the Refolding and Unfolding of Creatine Kinase

The effects of glycerol in the refolding, reactivation, unfolding, and inactivation of guanidine denatured creatine kinase were studied by observing the fluorescence emission spectra and the circular dichroism spectra, and by recovery and inactivation of enzymatic activity and aggregation. The results show that low concentrations of glycerol (<25%) improve the refolding yields of creatine kinase, but high glycerol concentrations decrease its recovery. Glycerol favors the secondary structural formation and inhibits aggregation of creatine kinase as proline does. These systematic observations further support the suggestion that low concentrations of glycerol possibly play a chaperone role in the refolding of creatine kinase. In addition, glycerol reduces the inactivation and unfolding rate of creatine kinase, increases the change in transition free energy of unfolding (ΔΔG u) and stabilizes its active conformation relative to the partially unfolded state with no glycerol. In the presence of glycerol, the inactivation and unfolding dynamics of creatine kinase are related to glycerol concentrations. Glycerol blocks the exposure of hydrophobic areas and the dissociation of dimers, and protects creatine kinase against guanidine denaturation in a concentration dependent manner. This study suggests that glycerol as an energy substrate for metabolism and organic components in vivo, assists correct protein folding, maintains adequate rates of enzymatic catalysis and stabilizes the protein secondary and tertiary conformations.

Characterization of the Partially Folded Monomeric Intermediate of Creatine Kinase

The importance of understanding the protein folding pathway and intermediates is well recognized on the basis of extensive studies of protein folding in vitro and in vivo. Creatine kinase (CK) is a typical model for studying unfolding and refolding of proteins due to several interesting properties. Recent studies on the folding of CK show that its partially folded monomeric intermediate is present kinetically and is stable at equilibrium. The present paper contains 33 references as a mini review to characterize the properties of CK from studies on the CK folding pathway. Characterization of these intermediates is an essential step toward understanding the mechanism of protein folding. Some well determined schemes are suggested as protein folding models.

CHANGES OF MYOCARDIAL MYOGLOBIN, MYOSIN AND CREATINE KINASE IN CASES OF SUDDEN NOCTURNAL DEATH SYNDROME

Myoglobin, myosin creatine kinase MM (CK-MM),creatine kinase BB(CK-BB) in cardiac muscle and H chain ofmyosin in atrial and ventricular muscle were studied in speci-mens from 8 patients who died of sudden nocturnal deathsyndrome(SNDS) by avidin-biotin complex (ABC) method toinvestigate the possible early or very early myocardial ischemiain the syndrome. Hematoxylin-eosin staining was conductedfor comparison. The results showed evident loss of CK-MM,CK-BB, myoglobin and myosin from cardiac muscle cells, indi-caring that occurrence of SNDS is closely associated withacute myocardial ischemia.

Analyses of N‑Terminal Pro‑Brain Natriuretic Peptide,Cardiac Troponin T,and Creatine Kinase MB in Pericardial Fluid in Sudden Cardiac Death Caused by Ischemic Heart Disease

Background:Biochemical analyses of N‑terminal pro‑brain natriuretic peptide(NT‑proBNP),cardiac troponin T(cTnT),and creatine kinase MB(CK‑MB)have been reported to be valuable for the auxiliary diagnosis of sudden cardiac death(SCD)in previous forensic studies.Aims and Objectives:The present study aimed to evaluate the diagnostic efficiency of combined analyses of NT‑proBNP,cTnT and CK‑MB in the pericardial fluid for forensic diagnosis of SCD caused by ischemic heart disease.Materials and Methods:Levels of NT‑proBNP,cTnT,and CK‑MB in the pericardial fluid of 132 medicolegal autopsy cases were obtained through electrochemiluminescence method.Results:NT‑proBNP,cTnT,and CK‑MB levels were significantly elevated in SCD cases(P<0.05).Receiver‑operating characteristics(ROC)analysis showed that NT‑proBNP,cTnT,and CK‑MB have diagnostic value for the diagnosis of SCD:NT‑proBNP,cutoff value of 2236 pg/ml;cTnT,cutoff value of 199.51 ng/ml;CK‑MB:cutoff value of 2742.5 ng/ml,and the combined analyses of these three biomarkers have better diagnostic efficiency than each single biomarker alone.Moreover,the causes of SCD were sub‑divided into acute ischemic heart disease,acute myocardial infarction(AMI),and recurrent myocardial infarction subgroups for further analysis,which revealed that the ratio of cTnT/CK‑MB could be used to distinguish AMI with the cutoff value of 0.1085 estimated by ROC analysis.Conclusion:These observations suggested that the postmortem biochemical analyses of NT‑proBNP,cTnT,and CK‑MB in the pericardial fluid may assist to diagnose SCD in forensic practice,and the combined analyses of multiple biomarkers have better diagnostic efficiency than each single biomarker alone.On the basis of the postmortem biochemical analyses of NT‑proBNP,cTnT and CK‑MB,combining the ratio of cTnT/CK‑MB could be used to distinguish AMI.

Electrophoresis of creatine kinase isoforms:a highly sensitive fluorescence scanning method

Objective To develop an agarose electrophoretic method for creatine kinase (CK) isoforms, using highly sensitive fluorescence scanning.Methods A discontinuous buffer system was used. Electrophoresis on agarose gel was performed under constant current and low voltage. CK isoforms were separated within 30 minutes and detected by fluorescence scanning.Results There were no significant differences when the activities of CK MM were between 853.0 U/L and 14.0 U/L and those of CK MB between 152.0 U/L and 2.4 U/L. The detection limits of stain method for CK MM and CK MB isoforms were 36.0 U/L and 12.3 U/L, respectively; while those of fluorescence method were 12.0 U/L and 2.1 U/L. The experimental results showed good precision for CK MM isoforms, as well for CK MB isoforms and isoenzymes.Conclusion An agarose electrophoretic method has been developed to measure CK isoenzymes and isoforms clinically. This method is rapid, simple, sensitive, highly reproducible and inexpensive. It is suitable for general laboratories.

Exertional Rhabdomyolysis Induced Acute Kidney Injury: A Case Report and Literature Review

Background: The exRML (exertional rhabdomyolysis) is a pathophysiologic condition of skeletal muscle cell damage and breakdown associated with high intensity or prolonged exercise, normal exercise under extreme circumstances, or sudden and excessive skeletal muscle contraction. It may manifest from the increase in CK (creatine kinase) or MYO (myoglobin), a protein that can cause life-threatening injury to the kidney (AKI, acute kidney injury), and may or may not be associated with myoglobinuria. Here, we presented a case of exRML with AKI, and then reviewed the related reports. Vigorous hydration, sodium bicarbonate and furosemide are key treatments. Aim: To examine an elderly patient with exRML induced AKI and the key treatment process. Case summary: A 61-year-old man left our hospital without permission after his admission and has been walking for almost 30 kms with no water and food intake, then was diagnosed exRML and exRML induced AKI with an obvious elevation of CK, MYO and decrease of eGFR (estimated glomerular filtration rate) after coming back, and was treated with vigorous hydration, loop diuresis, sodium bicarbonate, prostaglandin and Shenkang injection. After vigorous resuscitation, the patient’s renal function, CK and MYO returned normal. Conclusions: The exRML can cause serious complications such as AKI and death. Delayed diagnosis can be critical;therefore, manner of time should be taken to achieve a favorable prognosis.

The resistive range of motion exercise training in Duchenne muscular dystrophy:a case study

Background:To determine the effectiveness of resistive range of motion exercises in improving muscle strength and functional abilities in Duchenne muscular dystrophy.The study was also aimed to determine if resistive range of motion exercises can slow down the progression of the disease.Methods:A seven-year-old male child was diagnosed with Duchenne muscle dystrophy presented to outpatient physiotherapy clinic.The patient was presented with difficulty in stair climbing,sitting up from the floor,fatigue,and muscle weakness specifically weakness in the proximal limb muscles.The progressive resistive range of motion training was implemented for four years to improve muscle strength and functional abilities.The medical research council grading scale,north ambulatory assessment scale,and creatine kinase were used to evaluate muscle strength,functional abilities,and creatine kinase levels.Results:The muscular strength and functional abilities did not improve after four years of exercise training.The creatine kinase levels were decreased over the period of four years.Conclusion:Resistive range of motion exercises are helpful in maintaining the muscular strength and functional abilities in Duchenne muscular dystrophy.

Abnormal liver function tests associated with severe rhabdomyolysis

Rhabdomyolysis is a syndrome of skeletal muscle injury with release of cellular constituents such as potassium,phosphate,urate and intracellular proteins such as myoglobin into the circulation,which may cause complications including acute kidney injury,electrolyte disturbance and cardiac instability.Abnormal liver function tests are frequently observed in cases of severe rhabdomyolysis.Typically,there is an increase in serum aminotransferases,namely aspartate aminotransferase and alanine aminotransferase.This raises the question of liver injury and often triggers a pathway of investigation which may lead to a liver biopsy.However,muscle can also be a source of the increased aminotransferase activity.This review discusses the dilemma of finding abnormal liver function tests in the setting of muscle injury and the potential implications of such an association.It delves into some of the clinical and experimental evidence for correlating muscle injury to raised aminotransferases,and discusses pathophysiological mechanisms such as oxidative stress which may cause actual liver injury.Serum aminotransferases lack tissue specificity to allow clinicians to distinguish primary liver injury from muscle injury.This review also explores potential approaches to improve the accuracy of our diagnostic tools,so that excessive or unnecessary liver investigations can be avoided.

Application of Serum CK and BUN Determination in Monitoring Pre-Competition Training of Badminton Athletes

In order to investigate the feasibility of serum creatine kinase （CK） and blood urea nitrogen （BUN） in monitoring pre-competition training of badminton athletes, the pre-competition training load of 20 badminton athletes was studied, and serum CK and BUN were determined before, immediate and next morning after training. The results showed that after intensive training for one week, serum CK levels were significantly increased by 57.53 mmol/L （P〈0.05）. After regulation of the training intensity, average serum CK levels were increased by 21.79 mmol/L （P〈0.05）. BUN contents were increased by 0.83 mmol/L on average with the difference being not significant （P〉0.05）. After intermittent training, there was significant difference in the average increased levels of serum CK in athletes （P〈0.05）. There was significant difference before and after regulation of training （P〈0.05）. The increased levels of BUN were 0.78 mmol/L without significant difference （P〉0.05）. It was concluded that serum CK was one of the biochemical indicators monitoring the training load sensitivity of badminton athletes, but BUN was of little value in monitoring the training load. Both serum CK and BUN recovered slowly after one-week intensive training and intermittent training, suggesting the metabolic mechanism of human body in training needs further study.

Non-alcoholic fatty liver disease later diagnosed as myotonic dystrophy

BACKGROUND Myotonic dystrophy(MD)is sometimes accompanied by metabolic/endocrine disorders,including dyslipidemia,central obesity,and hypogonadism.Due to considerable individual differences in the severity and progression of myopathy,MD patients with minimal-to-mild muscle symptoms might be followed as having other diseases,such as non-alcoholic fatty liver disease(NAFLD).CASE SUMMARY A 40-year-old non-obese man without a history of regular ethanol consumption was referred to our hospital due to persistent liver dysfunction and hyperlipidemia.His body mass index was 23.4 kg/m2.Liver histology demonstrated macrovesicular steatosis,ballooned hepatocytes with eosinophilic inclusion bodies,and perisinusoidal fibrosis,leading to the diagnosis of nonalcoholic steatohepatitis(NASH).Although he had no discernable muscle pain or weakness,persistently high serum creatine kinase(CK)and myoglobin levels as well as the presence of frontal baldness,a hatched face,history of cataract surgery,and grip myotonia indicated the possibility of MD.Southern blotting of the patient’s DNA revealed the presence of CTG repeats,confirming the diagnosis.CONCLUSION When gastroenterologists encounter NAFLD/NASH patients,serum CK should be verified.If hyperCKemia,frontal baldness,a hatched face,history of cataract surgery,and grip myotonia are noted,the possibility of MD may be considered.