Physiology of Excitable Tissues

ACTION POTENTIALS IN
NERVES AND NMJ
Dr. Masika
Excitable Tissues
2018

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 References
1. Human Physiology, 6th ed. Berne & Levy
2. Review of Medical Physiology, 25th ed.
Ganong, 2015
3. Medical Physiology, 13th ed. Guyton & Hall
4. Textbook of Medical Physiology, Updated
Edition. Boron, 2006
5. Human Physiology, 14th Ed. Stuart Fox
6. Physiology, 5th Ed. Linda S. Costanzo
3
EXCITABLE TISSUES-NEURONS

4
 Neuron
Neuron or nerve cell is defined as the
structural and functional unit of nervous
system.
Neuron is similar to any other cell in the body,
having nucleus and all the organelles in
cytoplasm. However, it is different from other
cells by two ways:
1. Neuron has branches or processes called
axon and dendrites
2. Neuron does not have centrosome. So, it
cannot undergo division.
6
 MEMBRANE POTENTIALS

• The combined action of membrane transport

systems in a resting cell results in a steady state
condition in which stable ionic concentration
gradients exist across the membrane, and the
osmolarity remains constant to prevent changes
in cellular volume.
• Ionic gradients are responsible for the generation
of a resting membrane potential (RMP)
difference across the cell membrane of all cells in
which the inside of the cell is electrically negative
with respect to the outside
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 Ion channels

• Voltage-gated channels are opened or closed by

changes in membrane potential.
• The activation gate of the Na+ channel in nerve is
opened by depolarization; when open, the nerve
membrane is permeable to Na+ (e.g., during the
upstroke of the nerve action potential).
• The inactivation gate of the Na+ channel in nerve
is closed by depolarization; when closed, the nerve
membrane is impermeable to Na+ (e.g., during the
repolarization phase of the nerve action potential).
8
Functions of activation and inactivation
gates on the nerve Na+ channel

9
 Ion channels cont’

• Ligand-gated channels are opened or closed by

hormones, second messengers, or
neurotransmitters, e.g., the nicotinic receptor
for acetylcholine (ACh) at the motor end plate is
an ion channel that opens when ACh binds to it.
When open, it is permeable to Na+ and K+,
causing the motor end plate to depolarize.

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 ACTION POTENTIAL (AP)-(IMPULSE)
• Definition 1: An AP is a rapid depolarization that
occurs in an excitable cell (neurons and muscle
cells) initiated by an electrical event or chemical
stimulation that causes increased ion permeability
in the cell membrane
• Definition 2: Rapid changes in membrane
permeability characterized by depolarization of the
membrane potential from negative to positive,
followed by a return to negative membrane
potential.
• NOTE: A rapid change in membrane potential in
response to a variety of stimuli. 13
 ACTION POTENTIALS CONT’
• An AP is a rapid, all-or-none change in the membrane
potential followed by a return to the resting membrane
potential:
1. Voltage-dependent ion channels in the plasma
membrane are the basis for action potentials.
2. An AP is propagated with the same shape and size along
the entire length of an axon.
3. APs are usually initiated at the initial segment of the
axon.
4. The AP is the basis of the signal-carrying ability of nerve
cells.
5. The patterns of conducted action potentials encode the
information conveyed by nerve cells. 14
 ACTION POTENTIALS CONT’
• Occurs in excitable tissue (e.g., neurons, muscle cells)
and is the "language" of the nervous system (i.e., the
electrical signals that encode all information in the
nervous system).
• Depolarization is a change to a less negative membrane
potential (membrane potential difference is decreased).
• Repolarization is the return of the membrane potential
toward RMP following either depolarization or
hyperpolarization.
• Hyperpolarization occurs when the membrane potential
becomes more negative (membrane potential difference
is increased) beyond RMP.
15
 ACTION POTENTIAL CONT’
• Rapid depolarization after threshold voltage is exceeded
is due to the opening of voltage-gated Na+ channels.
• The peak voltage where rapid depolarization abruptly
ends and the membrane enters the repolarizing phase has
two components:
• Closure of inactivation gates on Na+ channels.
• Opening of voltage-gated K+ channels.
• Repolarization of the membrane potential progresses due
to the decreasing Na+ conductance and the increasing K+
conductance.
• Afterhyperpolarization occurs because K+ conductance
exceeds that at rest, causing MP to approach EK.
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 Generation of APs in skeletal muscle cells

• The membrane potential reaches a threshold value

(approximately -55 mV), which is required for activation of
fast, voltage-gated sodium channels.
• Rapid influx of sodium occurs, causing depolarization of the
cell; corresponding to the sharp upstroke of the action
potential.
• The membrane potential becomes increasingly less
negative as it depolarizes and approaches the equilibrium
potential for Na+.
• The overshoot potential is at the apex of the action
potential spike and corresponds to the period during which
the membrane potential becomes positive (+).
23
Generation of an AP in skeletal muscle cells Cont’

• Next, the membrane becomes more permeable to

K+, causing efflux of potassium down its
concentration gradient.
• This causes repolarization of the membrane
potential.
• The final phase of the action potential is
characterized by a slight hyperpolarization phase,
during which the Na+,K+-ATPase (sodium) pump
reestablishes the original sodium and potassium
electrochemical gradients across the plasma
membrane. 24
 Properties of APs
1. "All or none":
• Generation of an action potential is determined
solely by the ability of the stimulus to cause the
cell to reach threshold (i.e., it is "all or none").
• If the threshold potential is reached, an action
potential is generated; if it is not reached, no
action potential is generated.
• Regardless of stimulus intensity or energy
content, the action potential will have the same
amplitude.
25
Properties of action potentials cont’

2. Frequency
• Increasing stimulus intensity increases the
frequency of action potential generation.
• For example, in a mechanoreceptor of the skin,
the more the receptor is deformed (i.e., the
greater the mechanical energy applied), the higher
the frequency of action potential generation
(action potential amplitude remains unchanged).

26
Properties of APs cont’
3. Refractory periods
• During refractory periods, the cell is unable to
generate an AP.
• This is an important property of excitable tissue
because it prevents overly rapid generation of APs,
which might cause continual contraction (tetany).
a) Absolute refractory period:
• An AP cannot be generated, regardless of stimulus
intensity.

27
 Properties of APs cont’
a) Absolute refractory period cont’
• This occurs during the depolarization phase of the AP
and is due to closure of the sodium channel
inactivation gates.
b) Relative refractory period:
• Only a stimulus with intensity much greater than
threshold can stimulate another AP.
• This occurs during the repolarization phase and is due
to the inactivated conformation of the voltage-gated
sodium channels.
• The conductance of K+ is higher than in the resting
state, so the membrane potential becomes more
negative. 28
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30
Properties of APs cont’
c) Accommodation
• When cells are held in the depolarization phase or are
depolarized very slowly, the inactivation gates on sodium
channels automatically close, and there is no sodium
current.
• Even if the cell has reached its normal threshold potential,
it is impossible for the cell to generate another AP because
too few sodium channels are open.
• Is demonstrated in hyperkalemia, in which skeletal muscle
membranes are depolarized by the high serum K+
concentration. Although the membrane potential is closer
to threshold, APs do not occur because inactivation gates
on Na+ channels are closed by depolarization, causing
muscle weakness. 31
Properties of APs cont’
4. Conductance without decrement
• APs travel along a neuron with no decrease in
signal strength because of the presence of the
protein myelin, which acts as an electrical
insulator.
• At sites along the axon where myelin is absent,
the nodes of Ranvier, the AP must "jump"
from one node to another, a process referred
to as saltatory conduction.

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 RESTING MEMBRANE POTENTIAL (RMP)

• RMP is the potential difference that exists

across the membrane of excitable cells such
as nerve and muscle in the period between
action potentials (i.e., at rest).
• In expressing the membrane potential, it is
conventional to refer the intracellular
potential to the extracellular potential.
 RMP CONT’
• The resting membrane potential is established by
diffusion potentials, which result from the
concentration differences for various ions across
the cell membrane.
• (established by primary and secondary active
transport mechanisms.)
• Each permeant ion attempts to drive the
membrane potential toward its own equilibrium
potential.
 RMP CONT’

 The resting membrane potential of excitable cells

falls in the range of −70 to −80 mV.
 These values can best be explained by the concept
of relative permeabilities of the cell membrane.
 Thus, the resting membrane potential is close to the
equilibrium potentials for K+ and Cl− because the
permeability to these ions at rest is high.
 The resting membrane potential is far from the
equilibrium potentials for Na+ and Ca2+ because the
permeability to these ions at rest is low.
 What role, if any, does the Na+-K+ATPase play in
creating the resting membrane potential?

• The answer has two parts. First, there is a small

direct electrogenic contribution of the Na+-K+
ATPase, which is based on the stoichiometry of
three Na+ ions pumped out of the cell for every two
K+ ions pumped into the cell.
• Second, the more important indirect contribution is
in maintaining the concentration gradient for K+
across the cell membrane, which then is responsible
for the K+ diffusion potential that drives the
membrane potential toward the K+ equilibrium
potential.
 Na, K ATPase
• Na, K ATPase catalyzes the hydrolysis of ATP to adenosine
diphosphate (ADP) and uses the energy to extrude 3 Na+
from the cell and take 2 K+ into the cell for each molecule
of ATP hydrolyzed.
• It is an electrogenic pump in that it moves three positive
charges out of the cell for each two that it moves in, and it
is therefore said to have a coupling ratio of 3:2. It is found
in all parts of the body.
• Its activity is inhibited by ouabain and related digitalis
glycosides used in the treatment of heart failure.
 Summary
• Depolarizing excitable cardiac myocytes from a
membrane potential of −87 mV to −69.5 mV may be
enough to trigger extracardiac action potentials,
which may lead to a fatal arrhythmia!
• At rest, the membranes of excitable cells are far
more permeable to K+ and Cl− than to Na+ and Ca2+.
These differences in permeability account for the
resting membrane potential.
Thus, RMP reflects the equilibrium potential of the
ions with the highest permeability and equilibrium
potential (and concentration gradient across the
membrane).
Summary cont’

• For example, in the resting state of the

neuron, the membrane is primarily
permeable to potassium, so K+ makes
the largest contribution to RMP; this
explains why the RMP (roughly -70 mV)
of a cell approximates the equilibrium
potential for K+ (-90 mV).
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Myelin Sheath and Neurilemma: Formation

Figure 11.5a-d
 Hyperkalemia
• In hyperkalemia, the extracellular potassium
concentration is higher than normal, so there is
less of a driving force for K+ to leave the cell and
keep the membrane potential at -70 mV.
• The cell depolarizes enough to trigger the
closure of sodium inactivation gates.
• This depolarization brings the membrane closer
to threshold, but no AP is generated.
45
 AP propagation
• APs are only propagated in one direction along a nerve
axon or muscle fiber.
• The impulse in one area causes local current flow,
which depolarizes the adjacent area to threshold,
generating a new AP downstream.
• This process is repeated to propagate the AP signal
• Conduction is unidirectional because the upstream
region is in its refractory period.
• The speed of AP conduction is faster in larger diameter
fibers because they have lower electrical resistance
than small diameter fibers.
• Conduction speed is also increased by the myelination
of nerve axons. 46
 AP propagation cont’
• Myelin consists of glial cell plasma membrane,
concentrically wrapped around the nerve.
• In the peripheral nerves, the myelin sheath is
interrupted at regular intervals by uncovered
nodes of Ranvier.
• APs are propagated from node-to-node rather
than conducting along the whole nerve
membrane because voltage-gated Na+ channels
are only expressed at nodes of Ranvier.
• This process, called saltatory conduction.
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 Conduction velocity
• Conduction velocity is primarily dependent on
the presence or absence of myelin and the
diameter of the axon.
• Large-diameter, myelinated axons conduct
impulses much more rapidly (1 to 100
m/second) than small-diameter, unmyelinated
axons (<1 m/second).
• Not having nodes of Ranvier, unmyelinated
axons have to continually regenerate APs along
the entire length of the axon, resulting in a much
slower conduction velocity. 49
 Conduction velocity cont’

• If the distance between the nodes of

Ranvier is decreased along the length of an
axon (i.e., there are more nodes of
Ranvier), the conduction velocity will be
reduced because more APs need to be
produced. ↓ Distance between nodes of
Ranvier → ↓ conduction velocity

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Demyelination

• Diseases that result in demyelination of

either the central nervous system (e.g.,
multiple sclerosis) or the peripheral
nervous system (e.g., Guillain-Barré
syndrome) will significantly impede
nerve conduction speed, impairing the
function of the nervous system.

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 Guillain-Barré syndrome

• In Guillain-Barré syndrome, segmental

demyelination of peripheral nerves, nerve
roots, and their associated ganglia occurs.
• It typically manifests as ascending weakness
and paralysis, starting in the distal
extremities and rapidly traveling proximally.

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 Guillain-Barré syndrome cont’
• Paralysis may occur because of immunologic
destruction (By abnormal antibodies) of the
myelin sheath, effectively decreasing nerve
conduction velocity.
• The disease can cause fatal respiratory
paralysis, so prompt respiratory care and
support are crucial.
• Once the inflammation has subsided, the
nerves can remyelinate, and normal function
can be recovered.
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 Multiple Sclerosis (MS)

• Multiple sclerosis (MS) is an inflammatory

neurodegenerative disease, believed to be of
autoimmune etiology.
• It is more common in women than men, and
the usual age of onset is between 20 and 40
years of age.
• The inflammatory process of MS results in the
gradual destruction of myelin sheaths around
myelinated axons of the brain and spinal cord.
54
 Multiple Sclerosis (MS) cont’
• A wide variety of symptoms may occur, including
muscle weakness and paralysis; impaired coordination
and poor balance; depression; impaired speech;
memory problems; visual problems; altered sensory
perception; pain; fatigue; and bowel, bladder, and
sexual dysfunctions, resulting from the deficits in neural
conduction caused by damage to myelin sheaths and
underlying axons in the central nervous system.
• Diagnosis is based on clinical findings, MRI evidence of
demyelinating lesions of the brain and spinal cord, and
characteristic oligoclonal bands of γ-globulins in
cerebrospinal fluid (CSF).
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 Tetrodotoxin (TTX) and Saxitoxin
• Tetrodotoxin (TTX), one of the most potent poisons
known, specifically blocks the Na+ channel. TTX
binds to the extracellular side of the sodium
channel.
• Saxitoxin is another blocker of Na+ channels that is
produced by the reddish dinoflagellates that are
responsible for so-called red tides. Shellfish eat the
dinoflagellates and concentrate saxitoxin in their
tissues.
• A person who eats these shellfish may experience
life-threatening paralysis within 30 minutes after
the meal. 56
 Tetraethylammonium (TEA+)

• Tetraethylammonium (TEA+), another poison,

blocks K+ channels. TEA+ enters the K+ channel
from the cytoplasmic side and blocks the
channel because TEA is unable to pass
through it.
• The ovaries of certain species of puffer fish,
also known as blowfish, contain TTX. Raw
puffer fish is a highly prized delicacy in Japan.
57
Tetraethylammonium (TEA+) cont’

• Connoisseurs of puffer fish enjoy the tingling

numbness of the lips caused by the minuscule
quantities of TTX present in the flesh.
• Sushi chefs who are trained to remove the
ovaries safely are licensed by the government
to prepare puffer fish.
• Despite these precautions, several people die
each year as a result of eating improperly
prepared puffer fish. 58
 NOTE

• A cell is said to be hyperpolarized when its membrane

potential is more negative than the normal resting
membrane potential (RMP) for the cell
• a cell at membrane potential less negative than its
usual resting membrane potential is said to be
depolarized. The membrane potential is a function of
the individual concentration gradients for ions across
the cell membrane and the permeabilities of the
membrane to those ions.
• Threshold: The membrane potential at which an AP is
initiated. The threshold is ~15mV less negative than the
resting potential. 59
 Effect of Lidocaine on Nerve APs

• Lidocaine and other local anesthetic agents

block voltage-gated Na+ channels in the nerve
membrane.
• At low concentrations, this blockade results in a
slower rate of rise (dV/dt) of the upstroke of the
action potential.
• At higher concentrations, the upstroke is
prevented altogether, and no action potentials
can occur. 60
QUESTION

QUESTIONS 1. Based on your knowledge

of how nerve action potentials are
propagated, how would you expect
lidocaine to alter the conduction of the
action potential along a nerve fiber?

61
QUESTIONS 2: Multiple Sclerosis
(Myelin and Conduction Velocity)

Meg Newton is a 32-year-old assistant at a horse-

breeding farm in Virginia. She feeds, grooms, and
exercises the horses. At age 27, she had her fist
episode of blurred vision. She was having trouble
reading the newspaper and the fine print on labels.
She had made an appointment with an optometrist,
but when her vision cleared on its own, she was
relieved and canceled the appointment. Ten months
later, the blurred vision returned, this time with
other symptoms that could not be ignored.
62
QUESTIONS 2: Multiple Sclerosis
(Myelin and Conduction Velocity) cont’
• She had double vision and a “pins and needles”
feeling and severe weakness in her legs. She was
even too weak to walk the horses to pasture. Meg
was referred to a neurologist, who ordered a series
of tests. Magnetic resonance imaging (MRI) of the
brain showed lesions typical of multiple sclerosis.
Visual-evoked potentials had a prolonged latency
that was consistent with decreased nerve
conduction velocity. Since the diagnosis, Meg has
had two relapses, and she is currently being treated
with interferon beta. 63
 MS Questions

1. How is the action potential propagated in

nerves (such as sensory nerves of the visual
system)?
2. What is a length constant, and what factors
increase it?
3. Why is it said that action potentials
propagate “nondecrementally?”
4. What is the effect of nerve diameter on
conduction velocity, and why? 64
 MS Questions cont’
5. What is the effect of myelination on conduction
velocity, and why?
6. In myelinated nerves, why must there be periodic
breaks in the myelin sheath (nodes of Ranvier)?
7. Meg was diagnosed with multiple sclerosis, a
disease of the central nervous system, in which
axons lose their myelin sheath. How does the loss
of the myelin sheath alter nerve conduction
velocity?
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Transmission of action potentials between cells

• A synapse is the functional connection between a

neuron and a second cell. In the CNS, this other cell
is also a neuron. In the PNS, the other cell may be
either a neuron or an effector cell within a muscle
or gland.
• Although the physiology of neuron-neuron synapses
and neuron-muscle synapses is similar, the latter
synapses are often called neuromuscular, junctions.
• Action potentials can be transmitted between cells
by either electrical or chemical transmission.
 ELECTRICAL SYNAPSES
• Electrical synapses allow current to flow from one
excitable cell to the next via low resistance
pathways between the cells called gap junctions.
• Gap junctions are found in cardiac muscle and in
some types of smooth muscle and account for the
very fast conduction in these tissues.
• E.g., rapid cell-to-cell conduction occurs in cardiac
ventricular muscle, in the uterus, and in the
bladder, allowing cells in these tissues to be
activated simultaneously and ensuring that
contraction occurs in a coordinated manner.
 CHEMICAL TRANSMISSION

• Primary form by which action potentials are

transmitted
• Binding of the neurotransmitter (secreted
from the presynaptic cell) to a ligand-gated
receptor on the postsynaptic membrane
results in localized depolarization and
generation of an action potential in the
postsynaptic cell.
CHEMICAL TRANSMISSION CONT’
Sequence of Events at the
Neuromuscular Junction
Sequence of Events at the Neuromuscular Junction Cont’
1. APs are propagated down the motoneuron
2. Local currents depolarize each adjacent region to
threshold.
3. The presynaptic terminal is depolarized, and this
depolarization causes voltage-gated Ca2+ channels in the
presynaptic membrane to open.
4. When these Ca2+ channels open, the Ca2+ permeability of
the presynaptic terminal increases, and Ca2+ flows into the
terminal down its electrochemical gradient.
5. Ca2+ uptake into the terminal causes release of the
neurotransmitter acetylcholine (ACh).
6. To release ACh, the synaptic vesicles fuse with the plasma
membrane and empty their contents into the synaptic cleft
by exocytosis.
Sequence of Events at the Neuromuscular Junction Cont’
7.The smallest possible amount of ACh that can be released is
the content of one synaptic vesicle (one quantum), and for
this reason, the release of Ach is said to be quantal.
8. ACh diffuses across the synaptic cleft to the postsynaptic
membrane.
9.This specialized region of the muscle fiber is called the motor
end plate (MEP) which contains nicotinic receptors (NR) for
ACh.
10. ACh binds to the α subunits of the NR and causes a
conformational change. NR for ACh is e.g of a ligand-gated io
channel: It also is an Na+ and K+ channel.
11. When the conformational change occurs, the central core o
the channel opens, and the permeability of MEP to both Na+
and K+ increases.
 Sequence of Events at the Neuromuscular Junction Cont’
12. MEPPs can summate to produce the full-fledged EPP.
The spontaneous appearance of MEPPs proves the
quantal nature of ACh release at the neuromuscular
junction.
13. Each MEPP, represents the content of one synaptic
vesicle, & depolarizes the MEP by about 0.4 mV.
14. An EPP is a multiple of these 0.4 mV units of
depolarization.
15. MEP must depolarize from its resting potential of −90
mV to the threshold potential of −50 mV,, therefore,
depolarize by 40 mV.
16. Depolarization by 40 mV requires 100 quanta (because
each quantum or vesicle depolarizes the MEP by 0.4 mV).
Sequence of Events at the Neuromuscular Junction Cont’
17. When these channels open, both Na+ and K+ flow down
their respective electrochemical gradients, Na+ moving into
the end plate and K+ moving out, each ion attempting to
drive the motor end plate potential to its equilibrium
potential.
18. In reality, however, because other ion channels that
influence membrane potential are present in the end plate,
the motor end plate only depolarizes to about −50 mV, which
is the end plate potential (EPP).
19. The EPP is not an AP but is simply a local depolarization of
the specialized motor end plate.
20. The content of a single synaptic vesicle produces the
smallest possible change in Vm of the MEP, the miniature
end plate potential (MEPP).
 Sequence of Events at the Neuromuscular Junction Cont’
21. The EPP then spreads by local currents to adjacent muscle
fibers, which are depolarized to threshold and fire APs.
22. Although the MEP itself cannot fire APs, it depolarizes
sufficiently to initiate the process in the neighboring
“regular” muscle cells.
23. APs are propagated down the muscle fiber by a
continuation of this process.
24. The EPP at the motor end plate is terminated when ACh is
degraded to choline and acetate by acetylcholinesterase
(AChE) on the motor end plate.
25. Approximately 50% of the choline is returned to the
presynaptic terminal by Na+- choline cotransport, to be
used again in the synthesis of new ACh.
 NOTE
• Before an action potential arrives at the axon
terminal, many synaptic vesicles are already
attached, or docked, to specialized sites of the
presynaptic plasma membrane.
• Docking involves a SNARE complex of proteins that
bridge the vesicle membrane and the plasma
membrane.
• SNARE proteins (soluble N-ethylmaleimide-
sensitive factor attachment protein receptors).
• The SNARE proteins include one in the vesicle
membrane (synaptobrevin-2) and two anchored in
the plasma membrane (syntaxin andSNAP -25 ).
 NOTE CONT’

• When an action potential arrives at the presynaptic

axon terminal, depolarization opens Ca2+ channels
in the plasma membrane.
• Ca2+ enters the cytoplasm and binds to a Ca2+
sensor protein, termed synaptotagmin, anchored
to the synaptic vesicle membrane.
• this interacts with the SNARE complex and leads in
less than a millisecond to fusion of the vesicle and
plasma membrane, the formation of a pore, and the
exocytosis of neurotransmitter.
 NOTE CONT’
• After fusion, vesicles can undergo at least two
possible fates. At some synapses, vesicles
completely fuse with the membrane and are later
recycled by endocytosis from the membrane at sites
outside the active zone.
• At other synapses, especially those at which AP
firing frequencies are high, vesicles may fuse only
briefly while they release their contents and then
reseal the pore and withdraw back into the nerve
terminal (a mechanism called “kiss-and-run
fusion”).
 AGENTS AND CONDITIONS THAT ALTER
NEUROMUSCULAR FUNCTION
1. Lambert-Eaton syndrome
• Is a neuromuscular disease that has symptoms of
progressive muscle weakness and fatigue.
• The syndrome is caused by circulating antibodies to
presynaptic Ca2+ channels.
• The antibodies are made against the voltage-gated
calcium channels on the terminal bouton of the
presynaptic motor neuron.
• The antibodies bind to the channels and prevent Ca2+
entry into motoneuron terminals, thus preventing
depolarization and release of acetylcholine
Lambert–Eaton syndrome cont’
• Binding of these antibodies to the calcium channels
impairs neurotransmitter (acetylcholine) release by
inhibiting calcium influx, resulting in generalized
muscle weakness.
• Proximal muscles are affected more than distal
muscles. This disease is commonly associated with
carcinoma. So, it is also called carcinomatous
myopathy.
• This disease is characterized by several features of
myasthenia gravis. In addition, the patients have
blurred vision and dry mouth.
2. Botulinus toxin
Botulinum toxin is derived from the bacteria
Clostridium botulinum bacilli, which causes food
poisoning (botulism).
 Botulinus toxin blocks the release of ACh from
presynaptic terminals by destroying SNARE proteins,
causing total blockade of neuromuscular
transmission, Flaccid paralysis of skeletal muscle,
and, eventually, death from respiratory failure.
Low doses of one type of botulinum toxin (Botox)
are injected therapeutically to treat a number of
conditions, including facial wrinkles, severe sweating,
uncontrollable blinking, misalignment of the eyes,
and others.
 Botulinum toxin cont’

• In its purified form (Botox), this paralysis of

muscles is temporary (3–4 months) and is used
cosmetically to soften the appearance of wrinkles.
• It is also used therapeutically in the treatment of
many conditions, including cervical dystonia (a
neuromuscular disorder of the head and neck),
severe hyperhydriasis (excessive sweating),
achalasia (failure of the lower esophageal
sphincter [LES] to relax), and migraine.
 Tetanus toxin
• Tetanus is caused by the bacillus Clostridium tetani,
which produces a toxin (tetanus toxin).
• This toxin is a protease that destroys SNARE proteins in
the presynaptic terminal so that fusion of vesicles with
the membrane is prevented, inhibiting
neurotransmitter release.
• Tetanus toxin specifically affects inhibitory neurons in
the CNS that normally are important in suppressing the
neurons that lead to skeletal muscle activation.
• Therefore, tetanus toxin results in an increase in muscle
contraction and a rigid, or spastic paralysis.
 3. ALPHA -LATROTOXIN

A latrotoxin is a high-molecular mass neurotoxin found

in the venom of spiders of the genus Latrodectus
 (widow spiders). Latrotoxins are the main active
components of the venom and are responsible for the
symptoms of latrodectism.
Action: Enters motor nerve terminal, promotes massive
release of acetylcholine
Effect: Initial surge of acetylcholine release followed by
irreversible depletion of acetylcholine; contractions
followed by flaccid paralysis
 4. ω-Conotoxin
• A conotoxin is one of a group of neurotoxic peptides
 isolated from the venom of the marine cone snail, genus 
Conus.
• The cysteine arrangements are the same for omega, delta
and kappa families, even though omega conotoxins are
calcium channel blockers, whereas delta conotoxins delay
the inactivation of sodium channels, and kappa conotoxins
are potassium channel blockers
Action: Binds irreversibly to Ca2+ channels in motor nerve
terminal membrane
Effect: Reduced Ca2+ entry to nerve terminal, reduced
acetylcholine release; flaccid paralysis
 5. Neuromuscular depolarising blockers
• These agents act like acetylcholine (ACh) but are
resistant to the action of acetylcholinesterase (AChE)
(Competitive agonist of the postsynaptic nicotinic
receptor).
• Therefore their initial action is to depolarise and
consequently stimulate the contraction of skeletal
muscles.
• So, the muscle remains in a depolarized state for a long
time. But persistent depolarization leads to a block
possibly due to inactivation of voltage-gated sodium
channels.
• They cause flaccid paralysis. E.g., succinylcholine and
Carbamylcholine.
6. NEUROMUSCULAR NON-DEPOLARISING BLOCKERS

These drugs act by competing with Acetylcholine

(Ach) for the ACh receptors.
They block ACh receptors but do not have the
biological activity of ACh. By preventing ACh from
attaching to its receptors; these drugs block
neuromuscular transmission.
However, since the block is competitive, it can be
overcome by an excess of ACh. Important members
of this group are curare and gallamine (Flaxedil).
 7. A. Curare
• Curare is a plant product and is used by Red Indians
as an arrow poison. If an animal is hit by an arrow
poisoned with curare at its tip, the animal gets
paralysed and dies of respiratory failure within
minutes.
• Curare prevents the neuromuscular transmission by
combining with acetylcholine receptors. So, the
acetylcholine cannot combine with the receptors.
And, the endplate potential cannot develop. Since
curare blocks the neuromuscular transmission by
acting on the acetylcholine receptors, it is called
receptor blocker.
 7. B. Alpha- Bungarotoxin

• Is a toxin from the venom of deadly snakes.

It affects the neuromuscular transmission by
blocking the acetylcholine receptors.
(Irreversible antagonist at nicotinic
acetylcholine receptors). It causes flaccid
paralysis.
 7. C. d-Tubocurarine, pancuronium and
Atracurium

Action: Reversible competitive

antagonists at nicotinic acetylcholine
receptors.
Effect: Prevents acetylcholine action;
flaccid paralysis
 8. Acetylcholinesterase Inhibitors

• Drugs which inhibit AChE allow ACh released

at neuromuscular junctions to accumulate
instead of getting hydrolysed and recycled.
Accumulation of ACh initially leads to
widespread muscular contraction followed
by paralysis due to a depolarization block.
AChE inhibitors are also of two types:
reversible and irreversible.
 8 .a. Reversible AChE Inhibitors

• These agents are competitive inhibitors of AChE.

The block can be overcome by curare which can
compete with ACh for ACh receptors and
thereby reduce the intensity of the action of
accumulated ACh at the neuromuscular junction.
Important examples of this group are
physostigmine (a plant product also called
eserine) and its synthetic analogue, neostigmine
(Prolongs action of acetylcholine at the end
plate).
 8. b. Irreversible AChE Inhibitors

• These agents bind AChE so tightly that the block

is virtually irreversible. Some insecticides, e.g.
parathion, Malathion and Baygon, and some
agents (nerve gases such as SARIN) which may
be used in chemical warfare belong to this
group. Poisoning with these agents may initially
lead to convulsions and laryngeal spasm due to
muscular contraction followed by paralysis of
respiratory muscles and consequent death.
 Hemicholinium .9

Action: Choline reuptake blocker in motor

neuron terminal.
Effect: Depletes acetylcholine in nerve
terminals; muscle weakness or flaccid
paralysis
 10. MYASTHENIA GRAVIS
• Myasthenia gravis is an autoimmune disease of
neuromuscular junction caused by antibodies to cholinergic
receptors. It is characterized by grave weakness of the
muscle due to the inability of neuromuscular junction to
transmit impulses from nerve to the muscle. It is a serious
and sometimes a fatal disease.
Causes
• Myasthenia gravis is caused due to the development of
auto-antibodies (IgG auto-antibodies) against the receptors
of acetylcholine. That is, the body develops antibodies
against its own acetylcholine receptors. These antibodies
prevent binging of acetylcholine with it receptors or destroy
the receptors. So, though the acetylcholine release is
normal, it cannot execute its action.
 Symptoms of Myasthenia gravis
• Muscles which are more susceptible for myasthenia gravis are
muscles of neck, limbs, eyeballs and the muscle responsible for
eyelid movements, chewing, swallowing, speech and respiration.
• Patient is better early in the morning, because during the night
acetylcholine has accumulated and this can overcome the block
produced by antibodies to some degree. But the excess
acetylcholine cannot be maintained throughout the day, hence
patient gets weaker.
1. Early and prominent sign of this disease is drooping eyelids,
weakness of muscles of the upper eyelids leads to drooping
eyelids.
2. Facial, swallowing and mastication muscles are affected.
3. In severe cases, patient becomes bed ridden and may die from
respiratory paralysis.
 Common symptoms of myasthenia Gravis
• Slow and weak muscular contraction because of the defective
neuromuscular activity
• Inability to maintain the prolonged contraction of skeletal
muscle
• Quick fatigability when the patient attempts repeated
muscular contractions
• Weakness and fatigability of arms and legs
• Double vision and droopy eyelids due to the weakness of
ocular muscles
• Difficulty in swallowing due to weakness of throat muscles
• Difficulty in speech due to weakness of muscles of speech.
• In severe conditions, there is paralysis of muscles. Patient dies
mostly due to the paralysis of respiratory muscles.
Treatment of myasthenia gravis

Myasthenia gravis is treated by administration of

cholinesterase inhibitors such as neostigmine and
pyridostigmine. These drugs inhibit cholinesterase,
which degrades acetylcholine. So acetylcholine
remaining in the synaptic cleft for long period can bind
with its receptors. The situation in myasthenia gravis
bears a striking resemblance to that after administration
of curare. In both cases there is a competitive blockade
at the ACh receptor level which can be overcome by
AChE inhibitors. In contrast, note that the block
produced by AChE inhibitors may be overcome by curare
 What is the rationale behind the use of Calabar bean as a lie
detector by some native tribes of West Africa?

• Answer: Calabar bean contains physostigmine, an

AChE inhibitor. It is given to suspected criminals by
some native tribes of West Africa under the belief
that if the accused is innocent, nothing will happen to
him; but if he is guilty he will suffer and may even die.
The reason why this does often happen is that the
innocent person consumes it rapidly because he is
confident that nothing will happen to him. Rapid
consumption leads to local gastric irritation (possibly
due to accumulation of ACh at parasympathetic
postganglionic nerve endings in the stomach) and the
person vomits out the bean extract.
What is the rationale behind the use of Calabar bean as a lie
detector by some native tribes of West Africa? Cont’

• On the other hand the guilty person is scared

and apprehensive about the suffering that will
follow. Therefore he takes it in small sips. That is
why he suffers less gastric irritation, does not
vomit, and the bean extract reaches his small
intestines and gets absorbed. The result is that
he suffers the toxic effects of AChE inhibition.
Quite appropriately Calabar beans are also called
ordeal beans.
 11. Vesamicol
• is an experimental drug, acting presynaptically by inhibiting 
acetylcholine (ACh) uptake into synaptic vesicles and reducing its
release. Vesamicol may have applications in BAC therapy. It has been
described as a hydroxylated phencyclidine regioisomer.
• Mechanism of action: Vesamicol can be broadly categorized as a
cholinergic physiological antagonist, because it reduces the apparen
activity of cholinergic neurons, but does not act at the postsynaptic
ACh receptor. Vesamicol causes a non-competitive and reversible
block of the intracellular transporter  VAChT responsible for carrying
newly synthesized ACh into secretory vesicles in the presynaptic
nerve terminal. This transport process is driven by a proton gradient
between cell organelles and the cytoplasm. Blocking of acetylcholine
loading leads to empty vesicles fusing with neuron membranes,
decreasing ACh release.
 Question 3: Myasthenia Gravis:
Neuromuscular Transmission

• Wendy Chu is a 23-year-old photographer for a busy

local newspaper. Over the last 8 months, she
experienced “strange” symptoms. She had severe
eyestrain when she read for longer than 15 min. She
became tired when she chewed her food, brushed
her teeth, or dried her hair; and she had extreme
fatigue on the job. Despite her strong work ethic,
Wendy had to excuse herself from several “shoots”
because she simply could not carry the heavy
equipment.
Question 3: Myasthenia Gravis:
Neuromuscular Transmission cont’
• Wendy is not a complainer, but she began to worry
about these vague symptoms. She was evaluated by
her physician, who suspected myasthenia gravis.
While awaiting the results of a serum antibody test,
the physician initiated a trial of pyridostigmine, an
acetylcholinesterase inhibitor. Wendy immediately
felt better while taking the drug; her strength
returned to almost normal. Meanwhile, the results of
the antibody test were positive, confirming the
diagnosis of myasthenia gravis.
 Questions
1. What steps are involved in neuromuscular transmission?
2. What antibody was measured in Wendy’s serum? Against
what protein is this antibody directed?
3. Using your description of neuromuscular transmission,
explain why severe muscle weakness (e.g., ocular, jaw)
occurs in myasthenia gravis.
4. Why does pyridostigmine, an acetylcholinesterase inhibitor,
improve muscle strength in myasthenia gravis?
5. Consider the following drugs that act at various steps in
neuromuscular transmission. What is the action of each
drug, and which drugs are contraindicated in myasthenia
gravis? (Botulinus toxin; Curare; Neostigmine;
Hemicholinium)
109