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Unexpected Electrophysiological and Clinical Phenotype Correlations 7674 • The Journal of Neuroscience, May 20, 2015 • 35(20):7674–7681 Cellular/Molecular Novel SCN9A Mutations Underlying Extreme Pain Phenotypes: Unexpected Electrophysiological and Clinical Phenotype Correlations Edward C. Emery,1* Abdella M. Habib,2* James J. Cox,2* Adeline K. Nicholas,3 Fiona M. Gribble,1 C. Geoffrey Woods,3 and Frank Reimann1 1University of Cambridge, Wellcome Trust/MRC Institute for Metabolic Science, Addenbrooke’s Hospital, Cambridge, CB2 0QQ, United Kingdom, 2University College London, Molecular Nociception Group, London, WC1E 6BT, United Kingdom, and 3University of Cambridge, Cambridge Institute for Medical Research, Addenbrooke’s Hospital, Cambridge, CB2 0XY, United Kingdom The importance of NaV1.7 (encoded by SCN9A) in the regulation of pain sensing is exemplified by the heterogeneity of clinical phenotypes associated with its mutation. Gain-of-function mutations are typically pain-causing and have been associated with inherited eryth- romelalgia (IEM) and paroxysmal extreme pain disorder (PEPD). IEM is usually caused by enhanced NaV1.7 channel activation, whereas mutations that alter steady-state fast inactivation often lead to PEPD. In contrast, nonfunctional mutations in SCN9A are known to underlie congenital insensitivity to pain (CIP). Although well documented, the correlation between SCN9A genotypes and clinical phe- notypesisstillunclear.HerewereportthreefamilieswithnovelSCN9Amutations.InamultiaffecteddominantfamilywithIEM,wefound the heterozygous change L245 V. Electrophysiological characterization showed that this mutation did not affect channel activation but instead resulted in incomplete fast inactivation and a small hyperpolarizing shift in steady-state slow inactivation, characteristics more commonly associated with PEPD. In two compound heterozygous CIP patients, we found mutations that still retained functionality of the channels, with two C-terminal mutations (W1775R and L1831X) exhibiting a depolarizing shift in channel activation. Two mutations (A1236E and L1831X) resulted in a hyperpolarizing shift in steady-state fast inactivation. To our knowledge, these are the first descrip- tions of mutations with some retained channel function causing CIP. This study emphasizes the complex genotype–phenotype correla- tions that exist for SCN9A and highlights the C-terminal cytoplasmic region of NaV1.7 as a critical region for channel function, potentially facilitating analgesic drug development studies. Key words: congenital insensitivity to pain; inherited erythromelalgia; Nav1.7; pain; paroxysmal extreme pain disorder; SCN9A Introduction regulation of nociceptive neuron excitability (Dib-Hajj et al., Naturally occurring mutations in SCN9A have been linked with 2013). Gain-of-function mutations in SCN9A are linked with both hyposensitive and hypersensitive pain states, emphasizing debilitating, chronic pain syndromes, typified by inherited eryth- romelalgia (IEM), paroxysmal extreme pain disorder (PEPD), the important role of the encoded ion channel NaV1.7 in the and small-fiber neuropathy (SFN). IEM and PEPD are rare but clinically distinct conditions; IEM is characterized by an episodic Received Sept. 23, 2014; revised Feb. 25, 2015; accepted March 23, 2015. burning sensation in the hands and feet that is often coupled with Author contributions: E.C.E., J.J.C., F.M.G., C.G.W., and F.R. designed research; E.C.E., A.M.H., J.J.C., and A.K.N. redness and swelling, whereas PEPD is associated with extreme performedresearch;E.C.E.,A.M.H.,J.J.C.,A.K.N.,C.G.W.,andF.R.analyzeddata;E.C.E.,J.J.C.,F.M.G.,C.G.W.,andF.R. wrote the paper. bouts of pain within proximal regions of the body, typically rectal J.J.C. and A.M.H. were supported by an MRC Research Career Development fellowship. F.M.G., F.R., and E.C.E. and ocular. Patients with idiopathic SFN present with more wide- were supported by Wellcome Trust Senior Fellowships WT088357/Z/09/Z and WT084210/Z/07/Z and MRC Grant spread axonal degeneration resulting in pain and other sensory MC_UU_12012/3. C.G.W. was supported by the Cambridge Biomedical Research Campus. We thank Dr. Tony Jack- impairments, and a recent report found SCN9A mutations in 8 of son for helpful discussions while preparing this manuscript. 28 affected individuals (Faber et al., 2012). Loss-of-function mu- The authors declare no competing financial interests. *E.C.E., A.M.H., and J.J.C. contributed equally to this work. tations, by contrast, have been associated with a complete ab- This article is freely available online through the J Neurosci Author Open Choice option. sence of pain in affected individuals, a condition known as CorrespondenceshouldbeaddressedtoeitherDr.FrankReimann,UniversityofCambridge,InstituteofMetabolic congenital insensitivity to pain (CIP). Science, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom. E-mail: [email protected]. or Electrophysiological characterization has revealed that, like Prof. C. Geoffrey Woods, University of Cambridge, Cambridge Institute for Medical Research, Addenbrooke’s Hospi- tal, Hills Road, Cambridge CB2 0XY, United Kingdom. E-mail: [email protected]. other voltage-gated sodium channels, Nav1.7 shows voltage- DOI:10.1523/JNEUROSCI.3935-14.2015 dependent activation and inactivation, with the latter having fast Copyright © 2015 Emery et al. and slow components. Known SCN9A-associated CIP mutations This is an Open Access article distributed under the terms of the Creative Commons Attribution License CreativeCommonsAttribution4.0International,whichpermitsunrestricteduse,distributionandreproductioninany are incapable of supporting functional NaV1.7 expression, sug- medium provided that the original work is properly attributed. gesting a crucial role of this current for nociception (Cox et al., Emery et al. • Novel SCN9A Mutations in IEM and CIP J. Neurosci., May 20, 2015 • 35(20):7674–7681 • 7675 2006, 2010) and the essential dependence of nociception on added to each dish of cells, which were then incubated for 24 h at 37°C, ␤ ␤ Nav1.7 was recently confirmed in mice (Gingras et al., 2014). SFN 5% CO2. For the negative control, 1/ 2 cDNA (42.5 ng) was transfected mutations appear to impair the slow inactivation of Nav1.7 cur- alone. After 24 h, the cells were split and diluted 1:20 in culture medium rents, and it has been suggested that the resulting overexcitability and plated directly onto 35 mm dishes and incubated for 24 h. All cells results in an increased sensitivity of small-diameter DRG neurons were recorded from 24 to 48 h after transfection. Electrophysiological analysis. All electrophysiological recordings were to otherwise benign insults (Faber et al., 2012). Overexcitability is performed using an AxoPatch 200B amplifier and a Digidata 1440A also observed when mutations found in patients with IEM or digitizer (Axon Instruments), controlled by Clampex software (version PEPD are heterologously expressed in DRG neurons (Dib-Hajj et 10, Molecular Devices). Filamented borosilicate microelectrodes al., 2008; Estacion et al., 2008; Eberhardt et al., 2014); however, (GC150TF-15, Harvard Apparatus) were coated with beeswax and fire the underlying electrophysiological characteristics of the mutated polished using a microforge (Narishige) to give resistances of 2–3 M⍀. NaV1.7 are thought to differ from each other. IEM mutations gen- For voltage-clamp experiments, the following solutions were used. Ex- erally cause a hyperpolarizing shift in channel activation, whereas tracellular solution (values are in mM) as follows: 140 NaCl, 3 KCl, 1 PEPD is typically associated with a depolarizing shift in fast inacti- MgCl2, 2 CaCl2, 10 HEPES, 1 glucose, pH 7.4 with NaOH. Intracellular vation (albeit often incomplete), resulting in persistent and/or solution (values in mM) as follows: 107 CsF, 10 EGTA, 10 TEA.Cl, 2 MgCl , 10 HEPES, 10 NaCl, 1 CaCl , pH 7.2 with CsOH. Unless other- resurgent currents. Why, or how, subtle changes in channel gat- 2 2 wise stated, standard whole-cell currents were acquired at 25 kHz and ing result in different phenotypes is currently unclear, but rare filtered at 10 kHz (low-pass Bessel filter) at 22°-24°C. After achieving mutations found in patients with mixed IEM and PEPD symp- whole-cell configuration, a holding potential of Ϫ100 mV was applied toms have been shown to simultaneously display altered activa- and series resistance was compensated by 70%. All currents were leak tion and inactivation properties (Estacion et al., 2008). subtracted using a p/4 protocol. Liquid junction potentials were calcu- To further understand the effects of discrete molecular and lated using Clampex software and corrected for before analysis. For functional changes in both hyposensitive and hypersensitive resurgent current recordings, the ␤4 peptide (KKLITFILKKTREK, Invit- pain conditions, we electrophysiologically characterized four rogen) was included in the intracellular pipette solution at 100 ␮M. The peptide was added on the day of experiment from a 10 mM stock novel mutations in NaV1.7 identified in two individual cases of CIP (W1775R, A1236E, L1831X) and one case of IEM (ddH2O). Voltage-dependent activation was fitted to a Boltzmann equa- x Ϫ V ), where A1) ء (((tion y ϭ (A2 ϩ (A1 Ϫ A2)/(1 ϩ exp((V Ϫ x)/k (L245V). Surprisingly, all three CIP-related mutations gave h rev is the maximal amplitude, Vh is the potential of half-maximal activation, rise to functional NaV1.7 channels, exhibiting changes in acti- x is the clamped membrane potential, Vrev is the reversal potential, and k vation and/or fast inactivation gating properties, coupled with is a constant. Voltage dependence of inactivation was fitted to a single a significant reduction in total current. In contrast, the single ϭ Ϫ ϩ Ϫ ϩ Boltzmann equation: y (A1 A2)/(1 exp((x Vh/k)) A2,ora ((frac/(1 ϩ exp((x Ϫ x01)/ k1 ) ء IEM-related mutation showed no change in channel activa- double Boltzmann equation: y ϭ y0 ϩ A tion properties but did show significant changes in inactiva- ϩ (1 Ϫ frac)/(1 ϩ exp((x Ϫ x02)/k2))), where k1 and k2 were constrained tion properties. Our results challenge a simple correlation to 4.5. All Boltzmann equations were fitted using Origin software.
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